Loading...
HomeMy WebLinkAboutPerry Development Corp. - 12/31/2019Commonwealth 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., PERRY DEMASCIO Doing business as: PERRY DEVELOPMENT CORPORATION P.O. BOX 103 MANSFIELD MA 02048 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 : 4 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 16P Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 APPLICANT: �\ 2 i IJ i N A I-C_r_-- BUSINESS NAME: MAIL ADDRESS: U, /3o_ ( f _o_ 3 -- CITYITOWN: A /� S1 %� L STATE: M A ZIP CODE: o V O BUSINESS PHONE:0-08)3g-/y_TBUSINESSCELL: _sQ[vt_ap__ _ BUSINESS FAX: 6 �i�AA.3 3q E-mail: _ r�lX/N7a jGiU'4f/Q9.I a (°� AltE-mail: P iQnd_,Sc� jr;xa :cs1J FEDERAL ID/SS NUMBER: 6 LICENSE HELD: Town /I /}PS f ( eL. 0 Year Licensed LICENSE HELD: Town n4 l n3 F) /[` /- n Year Licensed LICENSE HELD: Town IW ©r+vn __ Year Licensed __— I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum 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 31 st yearly. FEE: $ 100.00 SIGNATURE: 4� /a 2jc ti` DATE: _LrJ 1 117 Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. KQk dtVic /aPpht"I �o�/i✓, se Signature of Individual or Corporate Warne By: Corporate Officer (Mandaton�, if Applicable) "*Social Security No. (Voluntanj) or Federal Identification Number *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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc S�L 1\ �1­ VDepartment of Int{ustripbAeeidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name Address F. d . It City/State/Zip: 6: FAI 0 Phone #: _roir- 3'" — / Lt 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. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit workers' comp. insurance required] 3. �No We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. t52, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I LF,�-1, Health Care f. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] r G L L 12.�+�"Other &eAl tJ' 1AfC &L/r jhLa7 \ny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information, 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an Ionization should check box #I. ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. isurance Company Name isurer's Address: ity/State/Zip: olicy # or Self -ins. Lic. #_ Expiration ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do herebyl-&-rtify, uud�y the plrr� s and penalties ofperjury that the information provided above is true and correct hone #: J o r— 3)_6` t{ 71 Official use only. Do not write is this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone