HomeMy WebLinkAboutJohn's Sewer & Pipe Cleaning, Inc. - 12/31/2021C
LICENSE NUMBER:
-f
BUSINESS NAME: :! 0 kn,S
MAIL ADDRESS: TOWN: L{ r&j PW U0604 STATE: M 0 ZIP CODE: 0 )SO1
NAME OF OWNER: S W v- 1' 1< fJ Dn) 0 1 d
BUSINESS TELEPHONE: CELL: S01 a�+s Sd )SFAX: -)7) Spa f Gaiy
EMAIL: g Co q (nGdUNG(do(T,CpM-
FED ID/SS NO: ,L- "1 yy,6,fSB
FEE PER TRUCK: $100
Truck Registration number: R ay 114
Truck Registration number: -'S ( 'S � N
Truck Registration number:
Truck Registration number:
Truck Registration number:
SEPTAGE PUMPERS:
ALT EMAIL: j n 1� QJG�nSL Lf t." CrN"
NUMBER OF TRUCK(S): ),
Circle one:
Septage
FOG
Circle one:
Septage
.rQa7
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: THURSDAY, NOVEMBER 12, 2020 TIME: 7:OOAM-11:00AM
PLACE: GILETTE STADIUM - PARKING LOT P10
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 Cease when pumping
acc rs for BOH records. aP 0 n
I acknowledge that all pumpers will record the % Combined Solids and Grease on t e 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: I CO.# �---DATE: I � ) / 5 /.W p 1)
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.
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Signature of Individual or Corporate Name ' By: Corporate Officer (Mandatory, if Applicable)
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**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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
wwiv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 3
Address: NCe
City/State/Zip: 0 b (
Phone #: )II �(0 7 G Cp 5S
Are you an employer? Check the appropriate box: Business Type (required):
1. ® I am a employer with (p( 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 (met. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑ Non-profit
30 We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have i0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.Q Health Care
with no employees. [No workers' comp. insurance req.] 121A Other DCCtt1 Cleg;I r''
*Any 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
organization should check box #1.
I am an employer that is
Insurance Company Nan
Insurer's Address:
City/State/Zip:
workers' compensation insurance for nay employees. Below is the policy information.
�i0 L• �r,r�tL, S �
6I(t,S3•()u
Policy # or Self -ins. Lic. # W y V P 3 l o -71-1 Expiration Date: la I I/.101 1
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 forth 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.
I do hereby certify, under the pains and penahies of perjury that the information provided above is true and correct.
Phone #• _7'�) SG S G G S J
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
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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 Person
Phone M