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HomeMy WebLinkAboutCryan Landscape Contractors - 12/31/2021# ­2, S�3-5 6 -- try© OE. { Town of Mansfield w Ton of Mansfield - Board of Health 6 Park Row 0 Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: David Flynn BUSINESS NAME: MAIL ADDRESS: Cryan Landscape Contractors 41 Walton St CITY/TOWN: Attleboro STATE: MA ZIP CODE: 02703 BUSINESS PHONE: 508-226-3363 BUSINESS CELL: 774-284-7015 BUSINESS FAX: E-mail: Alt E-mail: dave@cryanlandscape.com ID/SS NUMBER: 04-3545220 LICENSE HELD: Town Rehoboth, MA LICENSE HELD: Town Seekonk, MA LICENSE HELD: Town North Attleboro, MA Year Licensed 2019 Year Licensed 2016 Year Licensed 2018 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 31st yearly. FEE: $ 100.00 SIGNATI. DATE: 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 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 04-3545220 "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\slcite\Desktop\ScotCs Docutuents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): l . [ I am a employer with La employees (full and/ 5. ❑ Retail l� 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' camp. insurance required] g• ❑ 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 06n r.b,,Ar Vy� 1 f Insurer's Address: 7ci i' kk c �'a)u _C P6 gox Pt- fT City/State/Zip: JA,1k�eS - D&6.R�'y ��' (V7D3 Policy # or Self -ins. Lic. # 1i L11 U-m-1 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 certi er lit eSain is id penalties ofperjury lit at the information provided above is true and correct. — AA 1/ � 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 www.mass.gov/dia Phone