HomeMy WebLinkAboutWind River Envrionmental -12/31/2021�0—
Town of Mansfield
Town of Mansfield - Board of health s Park Row
Mansfield, MA 02048
Disposal Works Installer Application
LICENSE NUMBER: - LNINre
APPLICANT:
BUSINESS NAME:
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MAIL ADDRESS: A
CITYITOWN: VI ^ i STATE: bye/ ZIP CODE:
BUSINESS PHONE: ,T00 I�n "'t �{ �� BUSINESS CELL:
BUSINESS FAX: 1 r'"
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IDISSNUMBER: (:)L{ - �1 {� -��7 7
LICENSE HELD: Town Year Licensed
LICENSE HELD: Town l\V✓� - Year Licensed
LICENSE HELD: Town VJV "f4V }�.'� MJX� 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 31 st yearly.
FEE: $ 100.00
SIGNATURE: 4- —
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
\ The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston, MA 021I4-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Let=ibiv
Business/Organization Name: Wind River Environmental, LLC
Address. 46 Lizotte Drive, Suite 1000
City/State/Zip: Marlborough, MA 01752 Phone #: (800) 499-1682
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑✓
I am a employer with 757 employees (full and/
5. ❑ Retail
orpart-time).*
6.❑RestaurantBar/EatingEstablishment
2. ❑
I 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.
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
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. rNo workers' comp. insurance req.]
12.❑� Other Waste Management
-Any applicant that checks box #I must also till 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Starr Indemnity & Liability Company
Insurer's Address: One International Place, 13th Floor
City/State/Zip: Boston MA 02110
Policy # or Self -ins. Lie. # 1000003291 Expiration Date: 6/30/2021
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 certify, under the pains and penalties of perjury that the information provided above is true and correct
Signature: 1:74W.aL (�44&m, Date: 9/9/2020
978-841-5148
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
www,m s.gov/dia
Phone
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
hidividual or Corporate N�m
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"Social Security No. (Voluntary) or Fedeml
Identtfuxition Number
l ra w f l )UMUAI rF0
By: Corporate Officer (Mandatory, if Applicable)
U_C,
*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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