HomeMy WebLinkAboutJ. Mariano Construction Inc. - 12/31/2021ram'
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Town of Mansfield
Town of Mansfield - Board of Health 6 Park Rpw
Mansfield;,MA02048
Disposal Works Installer Application `°°;>F,
LICENSE NUMBER:
APPLICANT: Joseph Mariano
BUSINESS NAME: S.-Mariano Construction Inc.
MAIL ADDRESS: 104 BltterSweet Drive
CITY/TOWN: Seekonk STATE: MA ZIP CODE: 02771
BUSINESS PHONE: BUSINESS CELL: 401-556-4998
BUSINESS FAX:
E-mail: Mark4026@gmail.com
Alt E-mail:
EDERAL ID/SS NUMBER: 04-2822781
LICENSE HELD: Town Seekonk Year Licensed 2020-21
LICENSE HELD: Town Rehoboth Year Licensed 2020-21
LICENSE HELD: Town Swansea Year Licensed 2020-21
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 31 st yearly.
FEE: $ 100.00
(4if
SIGNATURE:
DATE:4 %� Z
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
N
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.
i
Signature of Individual or Corporate Name
04-2822781
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate 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.
Cc\Users\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
UlfBoston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Lel=_ibly
Business/Organization Name: J. Mariano Construction
104 Bittersweet Drive
City/State/Zip: Seekonk MA 02771 Phone #: 401-556-4998
Are you an employer? Check the appropriate box: Business Type (required):
L❑✓ 1 am a employer with 1 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ 1 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] 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]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12,G/ Other Construction
*Any applicant that checks box 91 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 N I.
I arm an employer that is providing workers' compensation insurance for my employees. Below is file policy information.
Insurance Company Name: HW. Lapointe Insurance
Insurer's Address: 177 Pleasant Street
City/state/zip: Fall River, MA 02723
Policy # or Self -ins. Lic. # 0615N79A
Expiration Date: 06/11/2021
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 ceN (yf under ll a puns and penalties ofperjury that 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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4• Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mnss.gov/dia