HomeMy WebLinkAboutG. Horne Pumping - 12/31/20194
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Disposal Works Installer's Permit
This is to certify that., GARRY HORNE
Doing business as: G. HORNE PUMPING
46 BURT STREET
NORTON MA 02766
is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or
repair individual sewage disposal systems. This permit is granted inconformity with the STATE
ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2019 unless sooner
suspended or revoked.
LICENSE NUMBER: 19
FEE $100.00
BOARD OF HEALTH
MlchaeCHeaCey, Chairman
Dee. 12, 2018 2:40PM
No, 0670 P, 8
TAX URTIECATTON PO12M
1 certify tinder the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature o�f �— al or Corporate Name
*"Social Security No. (Voluntary)Or Federal
Identification Number
By: Corporate Officer (Mandatary, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations, licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Usors\sl610\Dashtop'ScoiPs DOaUmae(iWF dUSOMishmonls- Temp\TAXCERTIFICATION FOR Kdac
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The Commonwealth of Massachusetts
Departinent of Indush'ialAceldents
j I Congress Street, Suite 100
of Boston, MA 02114-2017
wtvw.mass govIdia
Workers' Compensation Insurance Affidavit: General Businesses,
TO BE RILED WITH THE PERMITTING AUTHORITY.
ADDlicant Information Please Print Let=-N
Business/Organization Name:
Address: r w BUR ( e�+
City/State/Zip; IVOkTo /0 MA 4?7WPhone #: 06- 05 -,39 37
Are you an employer? Check the appropriate box: Business Type (required):
1 • ❑ I am a employer with employees (full and/ 5. Retail
or part-time).* 6. Q Restaurant/Bar/Eating Establishment
2, C4 I am a sole proprietor or partnership and have no ?• Office and/or Sales (inei. real estate, auto, etc.)
employees working for me in any capacity,
[No workers' comp. insurance required] 8. ❑ Non-profit
3. E] We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10,[] Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4. n We are a non-profit organization, staffed by volunteers,
with no employees, [No workers' comp. insurance req•] 12.2 Other _ Se Ail LCy
*Any applicant flint checks box MI must also fill out the seotfon below showing liteir workers' compensation policy information.
**If the corporate officers have exempted Themselves, but the corporation ling other employees, a workers` compensation policy is required and such an
organization should cheek box # I.
10111 all enrploper !lint is providing worlters' compensation fnsinmtcefor lily employees. Below is the policy frrfornmllon.
Insurance Company
Insurer's
City/State/Zip:
Failure to secure coverage as required under Section 25A of MOL a 152 can lead to tine imposition of criminal penalties of a
tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for Insurance coverage verification,
1 do bereby certify, under the pains all
fnforarodon provided above Is lryee
rlatn• % *N ' i'1_
Official use only. Do not Iprite frt this area, lobe completer) by city or town officlol.
City or Town:
Permit/Liconse
correel,
Issuing Authority (circle one):
1, Board of Health 2. Building Department 3. City/Town Cleric 4, Licensing Board 5. Selectmen's Office
6, Other
Contact
www.mass.gov/d(a
Phone
Dec. 12, 2018 2:38PN1 No. 0670 P. 1
J x To wit o f Marfsffeld -Board of flealtlz aid,R�i„3 .,.
y nsfi26DEL
Disposal Works Insialler
LICENSE NUMBER:
APPLICANT:
BUSINESS NAME:'�—
MAILADgRt;SS:
CITY/TOWN: �1�� _ STATE:��' ZIPCODE:
BUSINESS PHONE: =_ ' _ 'i ? BUSINESS CELL:
BUSINESS FAX:
Aft E-mail;
FEDERAL ID/SS NUMBER: (DL—L
LICENSE HELD: Town �- u Year Licensed ✓�__,
LICENSE HELD: Town "_ ` -_ Year Licensed _
LICENSE HELD: Town _ _ Year Licensed
I have read 310 OUR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimutrl Standards for the Subsurface Disposal of Sanitary Sewage".
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires December 31styaar4,.
FEE: $100.00
SIGNATURE: bn9ii'Lr �t / �✓�
DATE: ll._Q��- e ¢}L--
Please make appropriate changes. Sign, daie, and enclose check for $100.00 payable to Town of Mansfield.
Mail to: Board of Health, Town of Mansf/eld, SIX Park Row, Manpfielcf,, MA 02048