The URL can be used to link to this page

Home My WebLink AboutPatriot Services - 12/31/2021:056)- Novaik wanslield h f v 4 !F°ns nD�s Town of Mansfield 6 Park Row Mansfield, MA 02048 .S"eptage/FOG Haulers Application 1 DATE: LICENSE NUMBER: BUSINESS NAME: I t'UIY 01 rV ((�q� MAIL ADDRESS: TOWN: 150 X D(ALA " \ ' STATE: M NAME OF OWNER: Uhke C/o BUSINESS TEL``��EPH�OpNE ��&-t'j4'j -qgjD p°�� CELL: EMAIL:poin V� °� �IW � �1 11 A��' neA FED ID/SS NO: �u— 125 G 15t{ FEE PER TRUCK: $100 Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: ................................. SEPTAGE PUMPERS: ALT EMAIL: NUMBER OF TRUCK(S): ZIP CODE: ()at)A Circle one: Circle one: 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:OOAM 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 Grease when pumping ocgLrs for BOH 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 pa able to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. ) SIGNATURE: �\ �' l"� _ DATE: J y ,K Septage FOG Septage TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number B : orporate Officer (Mandatory, if Applicable) *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. CAUseN\sleile\Desklop\Scoffs Docnmenls\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ut- wwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Ayou an employer? Check th appropriate box: 1. I am a employer with employees (full and/ or Pat t-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ 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 employees. [No workers' comp. insurance req.] Phone Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 l.n Health Care Other *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 aun an employer that is providing workers' conpensadon insurance for nny employees. Below is the policy information. Insurance Company Insurer's Address:�� City/State/Zip: /L' Pwr n( 1 Policy # or Self -ins. Lic. #_ 3K �'� a Expiration Date: 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 of the DIA for insurance coverage verification. I do hereby cam%, under the pains and penalties ofpeijury thfrt 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.O her Contact Phone www.mass.gov/dia Customers we pump grease for in the Town of Mansfield: • Cafe on the Common 12 So Main Street Mansfield, Ma 02048 • Catman Cafd 16 Old Colony Rd Mansfield, Ma 02048 • Cold Stone Creamery 280 School Street Mansfield, Ma 02048 • Cumberland Farms 30 Chauncy Street Mansfield, Ma 02048 • D'Angelo's 260 Chauncy Street Mansfield, Ma 02048 • Deco's 365 N Main Street Mansfield, Ma 02048 • Dominos 235 Chauncy Street Mansfield, Ma 02048 • Flannel Cow Creamery 88 Chilson Ave Mansfield, Ma 02048 • Mansfield Deli 72 Pratt Street Mansfield, Ma 02048 • Sake Steak House 280 School Street Mansfield, Ma 02048 • Stefano's Pizza & Sub Shop 30 Chauncy Street Mansfield, Ma 02048 • Tasty Ray's 20 South Main St Mansfield, Ma 02048 • Wendy's 64 Copeland Drive Mansfield, Ma 02048 • White's Pastry 321 School Street Mansfield, Ma 02048