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HomeMy WebLinkAboutEveready Pumping Service - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: Mark Peterson, President Town of Mansfield 6 Park Row Mansfield, MA 02048 Doing business as: Mark Peterson Enterprises, Inc dba Eveready Pumping Service 8 Short St. South Easton MA 02375 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 111 section 31A and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 16 TRUCK REGISTRATION NUMBER(S): H51-302 BOARD OF HEALTH Dr. Raymond Martin, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2008 BUSINESS NAME: Mark Peterson Enterprises, Inc dba Eveready Pumping Service MAIL ADDRESS: 8 Short St. TOWN: South Easton STATE: MA ZIP CODE: 02375 NAME OF OWNER: Mark Peterson, President BUS TELEPHONE: (508) 238-6241 CELL: FAX FED ID/SS No: 04-3542102 NUMBER OF TRUCK(S): 1 �1 REGISTRATION NUMBER(S): H51-302I� FEE PER TRUCK: $50.00 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: _l,' jATE: .............................................................................................. TRUCKS INSPECTIONS: date: 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. AA Mobile Tank: 4 Securely mounted on truck Watertight Leak -proof cover Tight discharge tanks A = Acceptable NA = Not Acceptable AVenting of Mobile Tanks: Vent permits escape of gas, but not liquid X�. Hose: / Suction or pressure hose in good repare D.Puumps: A_Maintained to pre -e le ng f sewage Inspected by: /J, J� Inspected on: /�/ Z 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. re Ind��f��sor�v ��rs�l2p2%ins � * Signatuividual or Corporate Name (Mandatory) & &MIX-M�4�1�t By: Corporate Officer (Mandatory, if applicable) ©'l- 35`V 1,0A ** 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 600 Washington Street Boston, MA 02111 wwrv.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: AAk i I—elZ 5&161PA,2�l16iPSfS - W - ✓6bWi 41w� Address: 0 r�'l�lZf �7, City/State/Zip: j7/jt¢_Phone#: �Ug�'�lLt// Are ypu an employer? Check the appropriate box: Business Type (required): I. (Jf I am a employer with _ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑,�, /HHealth Care with no employees. [No workers' comp. insurance req.] 12.w Uther f 7^Q%N/j y/Lh t *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy informal ion. ~ **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 Address:_RO OX A-11 16 5,2UM /�iag,5 r ZW Zkf96,', Pt9 /0:709-00,�a City/State/zip: wil(&" sdRR� PR l�'7v-DF/Li? �_ Policy # or Self -ins. Lic. # 6-y� 0'V8 5_% Expiration Dater ZGf 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, finder the pains and penaltieWfperjury 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 Phone www.mass.gov/dia