HomeMy WebLinkAboutR. J. Gabriel Construction Co. - 12/31/2021+�1SK -/-I-?- - lv
Town of Mansfield - Board of Health
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Disposal Works Installer
LICENSE NUMBER:
APPLICANT:/3 f' ✓ / �_C _� __ s ;
BUSINESS NAME:
MAIL ADDRESS: �f f G' /S RZ)✓Z L� j
CITY/TOWN k�! -b( 37Z ✓C__. STATE: /fit h
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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ZIP CODE: e-R7'�aV-
BUSINESS PHONE: Z-Cc "j%lv ') 7 BUSINESS CELL:
BUSINESS FAX: �k' &q77 6 i/�
E-mail: i
Alt E-mail:
EDERAL ID/SS NUMBER:
LICENSE HELD: Town
LICENSE HELD: Town A
LICENSE HELD: Town (YC(�/
Year Licensed /710
Year Licensed j V I._'�
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
DA
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)
�a31-509�
*.*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.
C:\Users\sleite\Desktop\Scolt's DocumenlsTood Establishments- Temp\TAX CERTIFICATION FORM.doc
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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: (;_ 6,001E �2Z 4i5-, )�]E�,1fLl
Address: '
City/State/Zip: Ldll'Phone #: J7)- t17 —7 7 `
Are you an employer? Check the appropriate box: Business Type (required):
1./[z I am a employer with 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 e. 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, 1 l.❑ Health Care
with no employees. [No workers' comp, insurance req.] 1211 other �� I
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy intbnnation.
**If the coipmate 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 auz an employer that is providizzg workers' coazpezrsation insurance for nzv employees. Below is the policy information.
Insurance Company Name:_�� ��(l raj j
Insurer's Address:'
City/State/Zipft`C'Ci
Policy # or Self -ins. Lic. # _� " f%6 S y% �L - ��{,3 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 ttp 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
of the Dl, ._for insurance coverage verification.
I do hpt ehV Fortify, « f d,#r 01 e pans azzd penalties of perjury tdzat the infozazation provider! gbovf is true ruin correct.
Official use only. Do not write in this area, to be completer/ by city or lown offrcial.
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
NUMBER: 11
TOCOMMOUbjealtb 1 Ais e i `s ' .'r:
This is to Certify
David A. Gabriel
I.J. Gabriel Construction Co, Inc
785 Bedford Street
Bridgewater, MA 02324
Rio ljerebp graateb a Mi5pooal Vorlto Taotaller'o Vermit
To (fottotruct, alter, 3Jtlotall or Repair
%Hbibitmal Oeloerage )Biopooal 6potettto
191jio permit io gratrteb ht conformitp Will) the ffitate tftibiromttetttal Cabe title', 310
C;OI t anb expireo �Mecember 31, 2019 uttleoo 0OTr ottopeubeb or rebolteb.
�aatru �Otlk&iC0
J
$tebe 3fta `0;�
3(ulp to,,, 2019 data ourttier
NO 19-27
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF EAST BRIDGEWATER
BOARD OF HEALTH
This is to certify that
RJ Gabriel
785 Bedford Street
Bridgewater, MA 02324
FEE: $150.00
is hereby granted a Disposal Works Installer's License to construct, alter, install or repair,
individual sewage disposal systems.
This permit is granted in conformity with the State Sani
expires December 31, 2019, unless sooner suspended or re
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