HomeMy WebLinkAboutPodgurski Corp - 12/21/2009Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Septage Pumping and Transporting Permit
This is to certify that: P. CHRISTOPHER PODGURSKI
Doing business as: PODGURSKI CORP.
8 SPRINGDALE AVENUE
CANTON MA 02021
Town of Mansfield
6 Park Row
Mansfield, MA 02048
is hereby granted a SEPTAGE PUMPING AND TRANSPORTING PERMIT to engage in the pumping
or transporting of the contents of privies, cesspools, septic tanks and other offensive substances.
This permit is granted in conformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and
MGL chapter III section 31A and expires December 31, 2009 unless sooner suspended or revoked.
LICENSE NUMBER: 34
TRUCK REGISTRATION NUMBER(S): L37481
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
Town of Mansfield
Town of Mansfield - Board of Healt 6 Park Row
Mansfield, MA 02048
Septage Pumpers Application 0
DATE: 21�
BUSINESS NAME: Podgurski Corp.
MAIL ADDRESS: 8 Springdale Avenue
TOWN: Canton STATE: MA ZIP CODE: 02021
NAME OF OWNER: P. Christopher Podgurski
BUS TELEPHONE: (781) 828-0821 CELL: FAX: (781) 828-0438
FED ID/SS No: 04-318-7005 NUMBER OF TRUCK(S): 1
REGISTRATION NUMBER(S): L37481
FEE PER TRUCK/' $50.00
Please make appropriate changes. Sign, date, and enclose check payable to Town of Mansfield. Mail to:
Board of Health, Town7Man�sfield,
Six Park Row, Mansfield, MA 0204&
SIGNAT R ; ,. DATE: ) �)l J
..................................................................
TRUCKS INSPECTIONS: date: December 2nd & 3rd, 2008 time: 8:00 am to NOON
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 cannot make these dates.
FOR HEALTH AGENT'S USE ONLY
310 CMR: State Environmental Cdoe, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary
Sewage, 15.19 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents (2) 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: B. Venting of Mobile Tanks:
Securely mounted on truck Vent permits escape of gas, but not liquid
Watertight C. Hose:
Leak -proof cover Suction or pressure hose in good repare
Tight discharge tanks
D.Pumps:
Maintained to prevent leaking of sewage
A = acceptable Inspected by:
NA = Not Acceptable
Inspected on:
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 (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name: T o(,VA 1)( tiL.i U
City/State/Zip: t✓ aA�.. M. LM �V 02-0�-1 Phone #: � 531 ' b Z-� - O '�2-1
Are you an -employer? Check the appropriate box:
Business Type (required):
1. I am a employer with :51 employees (full and/
5. ❑ Retail
or 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. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.0Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We by
I I.❑ Health Care
are a non-profit organization, staffed volunteers,
with no employees. [No workers' comp. insurance req.]
12.0Other
'Any applicant that checks box #1 must also fit 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 is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
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 DIA for insurance coverage verification.
I do hereby certify❑( trf3egtie patio and petjafes of�erjury 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 M
www.mass.gov/dia