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HomeMy WebLinkAboutAndrew Webster - 12/31/2021APPLICANT: BUSINESS NAME: 0 oc 06262021 (�! f MAILADDRESS: c-\y V\OV-iQJ'A, Sttree-k awn of Mansfield Park Row ansfield, MA 02048 q. CITY/TOWN: �A` ���fl STATE: AN. ZIPCODE: 0,937S BUSINESS PHONE: BUSINESSCELL: (SCi�� `$�— \`too, BUSINESS FAX: tc , \ E-mail: �Qo ray\o v� Alt E-mail: ID/SSNUMBER: QS9L-(!'0—aZRj LICENSE HELD: Town O.Sa�©+f� Year Licensed LICENSE HELD: Town �� \ C7\Q2 VJ C?�C 2Y Year Licensed LICENSE HELD: 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 31st yearly. FEE: $100.00 SIGNATURE: DATE: Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mall 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. Signature of Individual or Corporate Name 032 GS S 39 "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. C:\Uscrs\.sleite\Desktop\Scou's Documents\Food Establislunents- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip: 1"0,!-,- "V0VX1 A k,1257S Phone#;(5m) t{n'-y7OC'v Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail 16 r part-time).* 6. ❑ Restaurant/Bar/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 me in any capacity. 8• ❑ Non-profit [No workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertahunent their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required] * 4. ❑ We are a non-profit organization, staffed by volunteers, 1 l.ealth Care 12. p� p Other du with no employees. [No workers' comp. insurance req.] �csJ�ST c� Ov1 *Airy 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's 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, underjhe pains,anrl penalties ofperjury that the information provided above is true and correct. Phone #: (SM) 43 1—1-7®0, 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.mass.gov/dia Phone