HomeMy WebLinkAboutPodgurski Corp. - 12/31/2021NAME OF OWNER: P. cha-i St�Pher Ppd gu s K l
BUSINESS TELEPHONE: -1�I—&2-g' 08Ll CELL:
EMAIL:mCUS-o� podguvsi6 eorp,coey)
FED ID/SS NO: 0 + �J ($ � ALT EMAIL:
FEE PER TRUCK: $100 NUMBER OF TRUCK(S):
Truck Registration number: Ori
Truck Registration number: 54
Truck Registration number:
Truck Registration number:
Truck Registration number:
SEPTAGE PUMPERS:
FAX:
Circle one:
eptage
FOG
Circle one:
Se a e
FOG
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 haven 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
occurs for BOH records.
I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs.
Alt 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 0204 .
SIGNATUR DATE: ' d %�o
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
tinder law.
1=
Signature of�ual or Corporate Name By: Corporate Officer (M d onj, if Applicable)
64318i-00,5
**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 tinder the authority of Massachusetts General Law
Chapter 62C, section 49A.
Ca\Users\sleite\DesktopGScoh's Docwaems\Food Establishments- Temp\TAx CERTIFICATION FORNI.doo
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of'Investigations
600 Washington Street
Boston, MA 02111
wwminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Phone #: -Ni- '2- 9,- 6 g-Z 1
Aru an employer? Check �the appropriate box: Business Type (required):
LLH I am a employer with ?r employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantBar/Eafing Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (mul. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. []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 10,❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ 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 #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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State
Policy # or Self -ins. Lic. # w 0 A 13 S ) SR--T Expiration Date: ID 2
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tinder 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.
Ido hereby corrttiifyy,,�under
nthe pains andpenalties ofpetymy that the information provided above is true and correct.
Signature: Date: / I I3c -�r
Phone #: % 9 1 — 9 2 9 6 g 2
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 Person: Phone #:
www.iiiass.gov/dia