HomeMy WebLinkAboutPodgurski Corp. - 12/31/2021Septage Pumpers Application
BUSINESS NAME: Pod �i V- 0 '3
MAIL ADDRESS: �i �- iniclo..E e
FIEN V l
LICENSE NUMBER:
TOWN: CCAn r) STATE: r-
NAME OFOWNER: P.ChPi P;y od a
BUSINESS TELEPHONE: `7 CELL:
E-mail Alt E-mail:
i�CbS� u��a�-p•-
FED ID/SS NO: r� NUMBER OF TRUCK(S):
REGISTRATION NUMBER(S): VS—+ 0
FEE PER TRUCK:
ZIP CODE: D2®5 `4
FAX: p % I — Z.` C) 1
Please make ap rop 'ate c an� .Sig date. and enclose check payable to Town of Mansfield. Mail to:
Board of Health, To � �nsfield, Si Park Row, Mansfield, MA 02048. rp
SIGNATORE.__•, DATE:
TRUCKS INSPECTIONS: DATE:
TIME:
PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO. MAIN STREET
PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THESE DATES
FOR HEALTH AGENT'S USE ONLY
310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage.
15.502 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents.
15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic
tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of
Health.
A. Mobile Tank:
Securely mounted on truck
Watertight
Leak -proof cover
Tight discharge tanks
A = Acceptable
NA =Not Acceptable
S. Venting of Mobile Tanks:
Vent permits escape of gas, but not liquid
C. Hose:
Suction or pressure hose in good repair
D. Pumps:
Maintained to prevent leaking of sewage
Inspected by:
Inspected on:
J
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.
Signatu of Individual or Corporate Name By: Corporate Officer (Mandy, ny, if Applicable)
"*Social Security No. (Voluntanj) 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:\Usem\sleite\Desktop\ScotCs Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
s` Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip: b 0 ! o Y`} 2, l Phone #:
Are yog an employer? Check the appropriate box:
Business Type (required):
1. I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Dar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for the 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. [No workers' comp. insurance req.]
12.❑ Other
*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 #1.
I ant an employer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
in i
Insurer's Address: r C)& -7 1 L
City/State/Zip:
I
Policy # or Self -ins. Lie. # W 1 t)0 Expiration Date: L 0 1 t
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.
Phone #: �§ C
Offtcial 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