HomeMy WebLinkAboutDJV Recycling, Inc. - 12/31/2020--� S S 1- IS 0, (!-
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Town of Mansfield - Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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Septage/FOG Haulers Application
DATE:
LICENSE NUMBER:
BUSINESS NAME: j7� V
MAIL ADDRESS: f , t4 o f C
I��X � G'.d
TOWN: CA STATE: P L r ZIP CODE: �`J t
NAME OF OWNER: 5 I} VC —
BUSINESS TELEPHONE: (06)Al ir?.j C, ,�JCELL: FAX:
EMAIL: 9) v r'r1 P � '� �c�.r, ALT EMAIL:
FED ID/SS NO: 6' :�?. Zvi �/ �' NUMBER OF TRUCK(S):
FEE PER TRUCK:r e
Truck Registration number: Tit%
Truck Registration number: ! /� 4
Truck Registration number:
Truck Registration number:
Truck Registration number:
SEPTAGE PUMPERS:
Circle one:
Septage
O
Circle one:
Septage
O
Circle one:
Septage
FOG
Circle one:
Septage
FOG
Circle one:
Septage
FOG
310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or
septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of
Health.
TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:OOAM
PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO
PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE
FOG PUMPERS:
Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations
Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield
will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as
part of the permit application.
PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping
occursforBOH records.
✓i acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs.
All documents must be completed signed and returned to the Health Department with the appropriate payment.
Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row,
Mansfield, MA 02048.
SIGNATURE: r DATE: /
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.
Signature of Individual or C#pacate Name By: Corporate Officer (Mandatonj, if Applicable)
"Social Security No. (Voluntary) 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\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department oflndustrialAccidents
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: C- 1 r s
City/State/Zip: lam) 0 � (- 1 Sr H Phone #: ( 5 v S, ) Ell
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. ❑1 estaurantBar/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.
o workers' comp. insurance required] 8• []Non-profit
3.e 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.n Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #I most 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
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 co ' 's-stiiement may be forwarded to the Office of
Investigations of the DIA for insurance coverage veri
I do hereby certifyfrnller tlyeymins^mul pen es of perjury that the information provided above Vtrue add correct.
Official use only. Do not write in 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