Loading...
HomeMy WebLinkAboutRiteway Construction - 12/31/2020o� (474 (-1 o©I Scanned with CarnScanner Town of Mansfield Town of Mansfield - Board of Health s Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER:_. 4�73 APPLICANT: BUSINESS NR MAIL ADDRESS: 10�i nJG(ai S i CITYrrOWN: �I�Q) /J STATE: M_ ZIP CODE: Q23 D BUSINESS PHONE: 7131-510—y,"j!D BUSINESSCELL: (.0 17 ^ BUSINESS FAX, NI i E-mail; ( (C1pul� 0 bri &4v Aft E-mail: ERAL ID1SS NUMBER: LICENSE HELD: Town _au : «__ r� <✓ Year Licensed 2 c) 19 LICENSE HELD: Town � 51n f yiG/��/Q�ti Year Licensed 7 d i_ _ s) LICENSE HELD: Town ?o 4 (fei -Affi-' L_ Year Licensed Z049 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: DATE: 17 311 I 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 Scanned with CamScanner 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. Als Signature of Individual or Corporate Name et''(-cnl3,vQ-tr .ir ni4 -13102 Y-'�Z- "Social Security No. (Voluntary) or Federal Identification Number By: Cortporate Officer (Mandatory, ii'Applicable) IC t -ly', tom coonS�YuGf', 9 L, "'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. r,u lu..\deimin..N.v.lCrnu'. n­lrn remm:.A...,..u_ T...nnkTevrvDglmoA"rn, vno,1 A... Scanned with CarnScanner The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leaib►v Business/Organization Are you an employer? Check the appropriate box; L ❑i I am a employer with t-- employees (full andt or Part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] I ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required] 4. ❑ We are a non-profit organization, staffed by volunteers with no emoloyees. [No workers' comp, insurance fort, Phone #: 20 I �:Ub Business Type (required): 5. ❑ Retail 6. ❑ Restr umnt/Bar/L•ating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) s. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I l,❑ Health Care 12.M Other R0 1, -*If the caporere olite n here exemped O,emselva, but the mrpoc-don hw othe "IDYeos, awakes' compwatiw polhY is Mcleod end such an orgenizmiw should check bat 61. am an employer that b providing workers' compearaaon insurance for my employees. Below is the polky Informadon. insurance Company Name: I M 10 C (h C � ! a_ _ Insurer's Address: AJnr'�,% iN1rl t r1 City/StatclZip: r I t policy q or Self -ins. Lie, 2 Z. % D I Expiration Date: L 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 ore. 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 under Official are only. Do not write in this area, to be completed by city or town of cIaL City or Town: Permit/License is true and correct Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. LlceesingBoard 5. Selectmen's Op➢ce 6.Other