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Town of Mansfield - Board of Health
Disposal Works Installer Application
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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LICENSE NUMBER:
APPLICANT: %14lrE t_,2 4 CC_{
BUSINESS NAME: --
MAIL ADDRESS:
CITY/TOWN: :�V-\t-4`��� STATE: ZIP CODE:
BUSINESS PHONE: �r v� _ ' �`2 } BUSINESS CELL: �' _2
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BUSINESS FAX:
E-mail: 6 .t1e, i[ !
Alt E-mail:
ERAL ID/SS NUMBER:
LICENSE HELD: Town G� I §t I f z v_) Year Licensed
LICENSE HELD: Town t �� iJ [ «�� Year Licensed
LICENSE HELD: Town
Year Licensed
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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:
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
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Department Qf Industrial Accidents
Office of Investigations
a 600 Washington Street
Boston, MA 02111
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Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
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City/State/Zip:
Are you an employer? Check the appropriate box:
I. ❑ I am �mployer with m eployees (fidI and/
o—rt-htne).'s
2. ❑ /1 ain a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]"
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #:
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I I.❑ Health Care
12.❑ Other
Any applicant that checks box MI nwst also fill out the section below showing their workers' compensation policy information.
'"I f the corporate officers have exempted themselves, but the coila ration has other employees, a workeis' compensation policy is requited and such an
nganization should check box it].
' mu an entploper that is providing marlcerrs' courpeitsation insurance for np, employees. Beloly is the policy information.
nsurance Company
usurer's Address:
-ity/State/Zip:
'obey It or Self=ins. Lie.
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
ine 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
If up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestieations of the DIA for insurance coverage verification. - -
do hereby cei ify, tTd r-d e pars and penalties of perjury that the information provided above is true and correct.
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�. Date:
itgnature: - —
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):
L Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person:
www.mass.gov/dia
Phoneth
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
-��-1631
**Social Security No. (Voluntary) o• Federal
Identification Nionber
*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.
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