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HomeMy WebLinkAboutDumont Pumping - 12/31/2021Town of Mansfield Town of Mansfield - Board of Health 6 Pa Row-"-, 1,1 M sfid, MA 02048, 1>1 I3iSP®SaC Works Installer Application LICENSE NUMBER: APPLICANT: 19 /e-6 i?l e 6 BUSINESS NAME: MAIL ADDRESS: Q1 f� COSY" //Lf4n A CITYITOWN: ) Y 4vr) STATE: 1 % ZIP CODE:, BUSINESS PHONE: ,049Ak,6 7993 BUSINESSCELL: BUSINESS FAX: E-mail: 0-L-✓va—el &_VeJyYOC&O GOfi JCCI SY • %( � Alt E-mail: EDERAL ID/SS NUMBER: Y J,93 '% ,6-7 LICENSE HELD: Town FiyX t ])et-t) Year Licensed LICENSE HELD: Town or /v P? Year LicensedIt LICENSE HELD: Town Year Licensed 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 SIGNATURE: DATE: 0P/ JJ/i%)f/GP 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) a -J 57,3 3 � _7 r "Social Security No. (Voluntanj) 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:\UserAsleite\Desktop\ScotVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc l ne C'ommonweaun of Massacnusetts 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: b er✓ Address: AIY6 C_tyl ' 111U117 Is) ✓ City/State/Zip: Nd /Toil/ 1'ltf - dp7 7lr 1/ Phone #: 5,0 ire yoy an employer? Check the appropriate box: Business Type (required): 1. I am a employer with v`+ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 1. ❑ 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] 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]**11.❑Health Care 1. ❑ We are a non-profit organization, staffed by volunteers, " with no employees. jNo workers' comp. insurance req.l 12.26ther key applicant that checks box #1 must also till 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 ganintion should check box #1. am an employer that is providing workers' compensation insurance for my employees Below is the policy information. isurance Company 'I-1e6 je1G isurer'sAddress: 74 ©J 7� C_ t /,,) /moo _z , GCV.5r J Itlk ity/State/Zip: J_o_e1450i? vi I le r�FL. a?A A 45 olicy # or Self -ins. Lic. # 416 O A L/ / A T Expiration Date: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Fup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of do hereby certify, under t e pains and penalties ofperjury that the information provided above 's true and correct. �. _ �o above 071 AeA� hone #:y 0 " j- _ A U 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 www.mass.gov/dia Phone