HomeMy WebLinkAboutPodgurski Corp. - 12/31/2008COMMONWEALTH of MASSACHUSETTS
TOWN of MANSFIELD
BOARD of HEALTH, SIX PARK ROW
SEPTAGE PUMPING AND TRANSPORTING PERMIT
This is to certify that:
Doing business as:
P. Christopher Podgurski
Podgurski Corp.
8 Springdale Avenue
Canton, MA 02021
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,
2008 unless sooner suspended or revoked.
LIC: 34
Truck Registration Number(s): L37481
TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD
SEPTAGE PUMPERS APPLICATION
Business Name:
Mail Address:
Town:
State:
Zip Code:
Podgurski Corp.
8 Springdale Avenue
Canton
11i�
02021
Name of Owner: P. Christopher Podgurski
Bus Phone: 7818280821 Fax: 781-828-0438
Fed ID/SS No.: 04-318-7005
Date: 2007
No. of Trucks: 1
Registration Numbers: L37481
Fee: $50.00t"Truck Signature: 4 V*6 � o -
Please make appropriate changes. Sign, date and enclose checkpayable to Town ofMansfaeld.
Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield MA 02048.
TRUCK INSPECTIONS. December 4th & 5th, 8:00am to NOON, at the Town Hall,
adjacent to South Common, Park Row, So. Main St. Please be there or call (508) 261-7366 if you
cannot make these dates. Thank you.
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 privies,
cesspools, 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 tank
e...� Watertight
�- Leak -proof cover
Tight discharge tanks
B. Venting of Mobile Tanks
L - 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
A = Acceptable Inspected by
NA = Not Acceptable Inspected on
R VlealtWanc's Oncuiiieii1sTER ll'APPLlCAIIONSNUWERS.doc
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.
�.,�I „'•
Signature of Individual or Corporate Name
"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.
R11iealtbUane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
I am a sole proprietor and have no one
�prking in any capacity.
am an emolover with �� emnfnw
I am an employer providing workers`
6 01/ a
U I am a sole proprietor and have hired
compensation polices:
Business Type: 0 Retail ❑ Restaurant/Bar/Eating Establishment
❑ Oflice ❑ Sales (including Real Estate, Autos etc.)
all 2 art time,. ❑ Other
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?ensation for my employees working on this job.
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contractors listed below who have the
company name: -
city: phone #
com en neme� - -
city: - . .
-`phone #:
Insurance co.- lic #
Failure to aceure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal pennitla of a fine up to $1,500.00 end/o
one years' imprisonment as well as civil pe 'l>w in the form 11 STOP WORK ORDER and a One of $100.00 a day ageltut me. I understand that a
copy of this statement ma - rd o the Ofrice-ef Inves�g' atiom of the DIA for coverage verification.
I do hereby
Print name _L h f 1
the information provided above is true and c rrect
Date
Phone #
omcial me only do not write in this area to be completed by city or tovm official
city or town: permnNcense q
❑HWlding Department
❑ check If Immediate response Is required ❑Llceming Board
❑Selectmen's Office
contact person: ❑Health Department
peened swt mall phone 0; ❑Other