HomeMy WebLinkAboutThomas Gottwald - 12/31/20216?
APPLICANT:
BUSINESS NAME:
MAILADDRESS:
Town of Mansfield - Board of Health
Mansfield, MA
Disposal Works Installer Application Z® 3
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CITY/TOWN: // p STATE:MA A ZIP CODE
BUSINESS PHONE: SO -`�S I �6 rBUSINESSCELL:^
BUSINESS FAX:
E-mail:
Alt E-mail:
ID/SS NUMBER:
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09
LICENSE HELD: Town ✓1" -15 Lt 'i ' Year Licensed C V 12'lW�-'r
LICENSE HELD: Town S Year Licensed
LICENSE HELD: Town � Z7J-L`)_4i✓U 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:
DATE: _.7/. 12-
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 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
A�;
Signature of Individual or Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, 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.
G\Users\sleite\Desktop\Sco(('s Documents\Food Establishments- 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
Applicant Information Please Print Legibly
Business/Organization Name: L/ lac 1 4VI ( / -P 1� r1 t-o
Address:
1A0
- ha-V1 AS
City/State/Zip:
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V40 c 2
Phone #: �� �- `1 �I
Are you an employer? Check the appropriate box:
Business Type (required):
5, ❑ Retail
1.❑ I am a employer with employees (full and/
or time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.
ttm a sole proprietor or partnership and have no
?, ❑ Office and/or Sales (met. 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] *
I LE] Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
1-Other 51 al
with no employees. [No workers' comp. insurance req.]
*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 #I.
I out 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
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.
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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/ora
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BOARD MEWERS
DR, BRYAN BACDASIAN
DR, Bnuly E. BODNER
DR, CHARLEs A. THAYER
HEATHER L. GALLANT; MPH. RS, OHO
EXEC1JT1vE DIRECTOR
ACAM 8. VICHSTMA
ARslarANr ExEaumr DmR (;rGR
DISPOSAL SYSTEM INSTALLER'S PERMIT
Permit #: 102 — 2020
Permit Fee: $100.00
This is to certify that:
Name: William Gottwald, William Gottwald
Address 40 Thomas Road, Berkley, NIA 02779
...is hereby granted a "Disposal System installer's Permit" to constrict, upgrade, expand and
abandon on -site sewage disposal systems in conformity with 310 CMR 15.000, The State
Environmental Code, Title 5
Type of permit and any restrictions: Disposal System Installer's Permit
Permit expiration date:
December 31, 2020 unless sooner suspended or revoked
Date issued: December 23, 2020
BOARD OF HEALTH
APPROVED
CHARLES A. THAYER, M.D.
CHAIRMAN
TAUNTON, MA
Adam S. Vickstrom
Assistant. Executive Director
Original installer
cc: Taunton Board of Health
Regional Environmental Engineer, DEP
Telephone (508) 821-1400 - Fax (508) 821-1403
Commonwealth of Massachusetts
Town of Stoughton
The following permits / licenses are granted to the undersigned establishment / person in accordance
with all applicable Conn non weal t It of Massachusetts General Laws and Regulations and the Rules and
Regulations of the'rown of Stoughton Board of 1-lealth.
This License is granted to:
William Gottwald
40 Thomas Road
Berkley, MA 02779
License Nwn; 2012-787
Date issued: 08/24/2020
License Expires Fee Notes
DWIP 12/3112020 100.00 Ufsposai,vocks insudlcr-in conl0mtfty �ciiN 310 (.'M12 ISAOQ
The state [nvirmonental Code, title 5.
Total 100.00
G--
Sean Leahy, Assistant own Sanitarian
( Expires on Date Shown unless sooner Suspended or Revoked
This License / Permit shall not be sold, assigned or Transferred
Post this License / Permit in a Conspicuous Place