HomeMy WebLinkAboutAnytime Septic Services - 12/3/12009Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Septage Pumping and Transporting Permit
This is to certify that. Christian Zahner IV
Doing business as: Anytime Septic Services Inc c/o Zway Corp
19 Purchase St
South Easton MA 02375
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 111 section 31A and expires December 31, 2009 unless sooner suspended or revoked.
LICENSE NUMBER: 15
TRUCK REGISTRATION NUMBER(S): J48-565
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 4� �
DATE: 2008
�I�� �cV u 20cs
BUSINESS NAME: Anytime Septic Services Inc c/o Zway Corp I0
MAIL ADDRESS: 19 Purchase St By
TOWN: S. Easton STATE: MA ZIP CODE: 02375
NAME OF OWNER: Christian Zahner IV
BUS TELEPHONE: (508) 821-7626 CELL: FAX: (508) 821-7502
FED ID/SS No: 04-3580612 NUMBER OF TRUCK(S): 1
REGISTRATION NUMBER(S): J48-565
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 _ ........... DATE: ✓�rS' Gid' -
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:
Securely mounted on truck
Watertight
Leak -proof cover
Tight discharge tanks
A = Acceptable
{ NA = Not Acceptable
B. Venting of Mobile Tanks:
Vent permits escape of gas, but not liquid
C. Hose:
Suction or pressure hose In good repare
D.Pumps:
Maintained to prevent leaking of sewage
Inspected by:
Inspected on: { ,9- /J) Off'
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 Indiviclug or
Corporate Name (Mandatory)
•r,datory, if applicable)
�'
I
** 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
low www.massgov/die
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Lettibly
Business/Organization Name:kW
Address:
City/Stateijf/// Phone #:
Ar�u an employer? Check the appropriate box: Busiaces Type (required):
orpart-time}.* $' � Rostau t&304,r ifirlg'l�sja �eNtpent
2. ❑ I am a solo 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] S. ❑ 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 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are anon-profit.organization, staffed by volunteers,; 11.QHealth Care
with no employees. [No workers' comp. itu umace req.] 12. Other �$02
"Any applicsnt that checks box #1 must also fill out the section below showing their Wotkm' wmpeosation polioy itifomastion.
"If the cogmmte officers havo exempted themselves, but the cotpotsdon has oW ter"Ployees, a workers' eompeasation p6licy is required sod such sn
organization should check box #t.
I am an employer that is providing workers' compensation h4uranee far my employees„ BeloIs the polky information.
Insurance Company Name: a, AIJ �r�
Insurer's Address.u/� �Oarz �4�,� r1? m /.df91's'
City/State/Zip:..��[ ai W-fi#/ &T.
Policy # or Self -ins. Lie. # 'a t5-77, Expiration Date: �� ��(k �4 _
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failuretosecure coverage.as.requireduwdrr,Secdon25AofMGL,452ean,leadtothe.impnsidon::ormitnimtLpenaluesofa
fine up to $1,500.00 and/or one-year imprisonment, as wellaS'ci Lpanal(aes m tke [oful ktfa�S O�;WORK RDERaMd"a'�fine
Of up to $250.00 a day against the violator. Be advised that a cop} of iluis statement rmay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerdA, under the pains and pen ofperjury that the information provided above is true and correct
Signature: Date:
official use only. Do not write in this area, to be completed by city
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 #b
www.moso.gov/dis