HomeMy WebLinkAboutRibeiro Enterprises, Inc. - 12/31/20214 i 0155 l
Town of Mansfield - Board of Health
M
Disposal Works Installer Application
LICENSE NUMBER:
APPLICANT:
BUSINESS NAME: /V ,l el/°
MAIL ADDRESS:
4/
E.
Town of Mansfield
6 Park Rb%k
CITY/TOWN: ��� STATE: _ ZIP CODE:
BUSINESS PHONE: %6i BUSINESS CELL: ok—_3 f -7 _ /,14 3
BUSINESS FAX:
E-mail:yl=9Y/Lf�eri�(�
Alt E-mail:
ID/SS NUMBER:
LICENSE
HELD:
Town F�12>7/�
Year Licensed
27A'F_
LICENSE
HELD:
Town
Year Licensed
2-M t
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:
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.
F14eiry 6-hl?iyses �.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
o
"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:\UsemWeite\Desktop\ScoMs Documents\Food Eslablishmen(s-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
Business/Organization Name:.
Address:
City/State/Zip:
Ao
//OYL '/V M 9— 0'D'76l phone #:
Are you an employer? Check the appropriate box: Business Type (required):
1. 41 am a employer with �_ employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (met. 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 75 -e/Z// L'✓
*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 #l.
I am an employer that is providiygiworkers' compensation insurance for my employees. Below is the policy information.
Insurance Company
i4 EGG
Insurer's Address: �✓/ l
City/State/Zip:i�y s ✓� /�� G�'%i 7
Policy # or Self -ins. Lic. # W6v-rd----2 83G Expiration Date: 7 l° ?Z1-7>-° _
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 certify, under the pains and penalties ofperjury that the information provided above is true and correct.
Signature:
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.mass.gov/dia