HomeMy WebLinkAboutUnited Hauling, Inc. - 12/31/2021A
n of Mansfield - Board of Health
Hauler's Application
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER:
TOTAL FEE: '3� -Q J. L
BUSINESS NAME: `��(y^ C C 0-J(h � g j t
BUSINESS ADDRESS: G� C°` w j"' l t' b-ex ��1, q S u l h e
TOWN / STATE / ZIP:S�
NAME OF OWNER:UgOY�it
TELEPHONE NO: Lo 9&D 4
CELL NO:
E-mail:
Alt E-mail:
FED ID/SS NO:
REGISTRATION NO: -3 iu$6) FE Oi-:bl ) �E ® 130
NO OF TRUCK(S): 3
FEE PER TRUCK: $75.00
, v fo(m*eq
Permit Expires December 31st yearly.
SIGNATUR DATE:
Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of
Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
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Town of Mansfield - Board of Health
Trash Hauler's Application
BUSINESS NAME:
BUSINESS
TOWN / ST,
TELEPHONENO: 5D1�'-I 5a- (.0900
CELL NO: '509 - 9100 - b qcf a
FAX NO: q�(� - aoco' acDaa.
uGT7I�T1:�'C�i�MIX
ALTERNATE EMAIL:
FED ID/SS NUMBER:
REGISTRATION NO:
NO OF TRUCKS:
FEE PER TRUCK: $75.00
TOTAL FEE TO BE PAID: $ '1 5 , b0
C,Z•M- � I q I qD
Town of Mansfield
6 Park Row
Man4fh6ld,4ViA 02048
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DATE: /0 -/ 3 -a0aLo
Please make appropriate changes. Sign, date and enclose check 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.
Una'2Pl Rud1itA Ind i A, 'i1�-e� _
Signature of Individual or orporate Name By: orporate O er Sandatory, if Applicable)
Su-a9 39 s (o 5
"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:\Usem\s1eite\Desktop\Seoti3 Docwentffood Establishments-Temp\TAX CERTIFICATION FORM.doc
Department of Industrial Accidents
Office of Investigations
. d 600 Washington Street
a
l` Boston, MA 02111
a www.mass.gov/dia
Worliers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
LLh
)-rn
City/State/Zip: tNtc,M ffift O leg \ Phone #: f) - 15 a - tpq on
Are you an employer? Check the appropriate box: Business Type (required):
1. ® lama employer with lJ 0 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.
[No workers' comp. insurance required] $• Non-profit
3.❑ We are a corporation and its officers have exercised 9. Entertainment
their right of exemption per c. 152, § 1(4), and we have 10Manufacturing
no employees. [No workers' comp. insurance required]** I l.� Health Care
4. We are a non-profit organization, staffed by volunteers, `.t y�
with no employees. [No workers' comp, insurance req.] 12.N Other WOt�tX Q( C In 0�
*Any applicant that checks box 91 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
organization should check box #I.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy information.
lA. l
Insurance Company Name: NM t%-"LO
Insurer's Addr
City/State/Zip:
Policy # or Self -ins. Lie. # �_i M-L-SQ0 --�'60076Lf 5 —a,&j O& Expiration Date: I— 1-00C.111
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 copy of this statement may be forwarded to the Office of
Investigations oUhe DIA for insurance coverage verification.
I do hereby celtio, under the painyAnd penalties of perjury that the information provided above is true and 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 Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia