HomeMy WebLinkAboutUS General Inc. - 12/31/20214 2I�4 ®(V0.®!
Town of Mansfield - Board of Health
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Disposal Works Installer Application
LICENSE NUMBER:
APPLICANT: , !�C S 4,,e�n�
BUSINESS NAME: a!:
MAIL ADDRESS:
CITY/TOWN:
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own`ofl iefd,) 21)
Park Row
4ansfield, MA 02048
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STATE: " ZIP CODE: d,�c,Ki—
BUSINESS PHONE: S'0,5- a7 ��/ % BUSINESS CELL:
BUSINESS FAX:
E-mail: .sQQ AK;D eAge tC6V° E
Alt E-mail:
ID/SS NUMBER: g4�0 7o /
LICENSE HELD: Town
Year Licensed `/ / '—
LICENSE HELD: Town V Vi�f�Uf\ Year Licensed / %
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LICENSE HELD: Town �CQ(� (` Year Licensed / p % --
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
SIGNATURE: Lid/_
DATE: v v 090
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.
/,,,, /, I
Signature of Individual or Corporate Name
4Social Security No. (Voluntani) or Federal
Identification Number
By: Corporate Officer (Mandaton/, 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.
C:\Users\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
wwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip:
'iei_-..
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.VO I am a sole proprietor or partnership and have no
y, ❑Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have
WE Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box #I 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 #I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. # 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 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/{& for insurance coverage verification.
I do hereby certi�f unde ins aa�_v aefperjury 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):
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