HomeMy WebLinkAboutST5 Septic Services, Inc - 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:
Nancy Wales
ST5 Septic, Inc.
59 Geordan Ave.
Wrentham, MA 02093
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: 25
Truck Registration Number(s): MA K77954
BOARD OF HEALTH
Dr. Raymond Martin, Chairna6
TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD
SEPTAGE PUMPERS APPLICATION
Business Name:
Mail Address:
Town:
State:
Zip Code:
Name of Owner:
Bus Phone:
Date:
No. of Trucks:
Registration Numbers
Fee: $50.00/Truck
ST5 Septic, Inc.
59 Geordan Ave.
Wrentham
MA
02093
Nancy Wales
5083847322
04-3555192
2007
1 Truck
: MA K77954
Signature:
Fax:
Please make appropriate changes. Sign, date and enclose check payable to Town of Mansf eld.
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. M bile Tank
Securely mounted on tank
B. V_Watertight
Leak -proof cover
Tight discharge tanks
entlinggof Mobile Tanks
Vent permits escape of gas, but not liquid
C. Hos
Suction or pressure hose in good repair
D. Pumps
Ma* ained to prevent leaking of sewage
A = Acceptable
NA = Not Acceptable
Inspected by,,,,,,
Inspected on
RAH,.WNnne's Daa ,nm WERMIT APPLICATIONSWOMPERSAdo
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.
S-T 6 �zv 1'e, (!Am 0, — 4p tqIW6n,
Signature of Individual or Corporate Name By: Corporat fficer (Mandatory, if Applicable)
*"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security nu.-nber 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.
R:\HealthVan&s Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Offree of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C6Y�5 �0 TT)C
Address:
City/State/Zip:
#: SC" 8- ` c7 �-y 7,5Cq
Are you an employer? Check the appropriate box: Business Type (required):
1. ® 1 am a employer with _ 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 (met. 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 WE Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑ Health Care �. n
with no employees. [No workers' comp. insurance req.] 12.0 Other �� &wzeodL11
'Any applicant that checks box #] 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 niy employees. Below is the policy information.
Insurance Company
Insurer's Address: Q�n kt m/n (DI
City/State/Zip:
Policy # or Self -ins. Lic.
L
Expiration Date: //0 _0 2s
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 certi, jy, under the pains and penalties ofperjury that the information provided above is true and correct.
Phone#
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 #: