HomeMy WebLinkAboutAnytime Septic Services, Inc. - 12/31/2008COMMONWEALTH OF MASSACHUSETTS
TOWN OF MANSFIELD
SIX PARK ROW, MANSFIELD, MA 02048
DISPOSAL WORKS INSTALLER'S PERMIT
This is to certify that:
CHRISTIAN ZAHNER IV
doing business as. -
ANYTIME SEPTIC SERVICES INC c/o Zway Corp
19 PURCHASE ST
S. EASTON, MA 02375
is hereby granted a DISPOSAL WOREfS INSTALLER PERMIT to construct, alter,
install, or repair individual sewage disposal systems. This permit is granted in
conformity with state environmental code 310 CMR 15.02(2) and expires December 31,
2008, unless suspended or revoked.
License Number: 68
Fee: $25.00
BOMBS� 0�D/_\tlllla
Dr. Raymond Martin, Chairman
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
DISPOSAL WORKS INSTALLER APPLICATION
LIC: 68
APPLICANT: CHRISTIAN ZAHNER IV
BUSINESS NAME: ANYTIME SEPTIC SERVICES INC c/o Zway Corp
MAIL ADDRESS: 19 PURCHASE ST
YC�1./�� i`I�.`]��/:F.`�C�]��Yll►��M�► G�i11ZK�71�IZ�tIrF
BUSINESS PHONE: (508) 821-7626
FAX NUMBER:
FED ID/SS NO
(508)821-7502
04-580612
I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary
Sewage". I understand that deviation from them may be cause for revocation of this
permit.
Permit Expires December 315t yearly
Fee: $25.00
SIGNATU e
DATE: r%
Please make appropriate changes. Sign, date and enclose check for $25.00 payable to Town
of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA
02048.
R \HnItWane's Donmteins\PERMIT APPLICATIONSVNSTALLERS 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.
1
Signature of Individual or Corporate Name By: Co Aerate Offic r ( ndntory, 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 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.
R:\Hmlth\Jan&s Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
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600 H'oshingfotn ,Street
Boston, AliH 02111
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141 1 t am a a mployer with j_ c nployr es (fill and/ 5.. Retail
orppuhlimc):* G,,L;stttolislnrcnt
Z. Ll I am a sole proprietor or padrict.;hrp and have no
1 LJ O lice and/or Silvis (incl. iced estate, auto, etc.)
emprgyees working for mein any capacity.
No workers' comp insurance required]prolil
10 We are aernporat,onandits olhcclShave exercised 9, f Gnlertaiumcut
their right ol'cxomption pet' e 1 i2, § 4 and we have
no employees ' - 10 �) Manutiwhrring
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_ with noempkWoes [Noworkws emu, heuranocuqj 112 )ther_
;Any .yapbcaot that chi k: box ll l mu ,t nl�o fill aut the semtiun below showia6 -'heir worke n co,opcos'anon policy alrouuauun,
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/ Out rrlT srnpta}'Cr'thTlt {}' J Yqi"1(1{"fAf n o'44'evcompensation insurance ,J Y Itly ('Jt111(r1r (E'S'. % L'J/HN TS' l/1g I!O%ic. in iprojoy on,
ln,ruanceCompany Name:
Insurer's Addlcsc
Policy 8 or Self ins. I,ic,.
AAA It copy of the workers' compensation perlicy declaration pale (showing Ow policy number and mpiratinn tow).
Failure to secure coverage as required under Section 25A of MCiL c. 1:52 can lead to the im po.silion ofel iloinal perialtics of a
line up In $ I,Sh0 0Q andlUrOMYCOr impl,^oumon' as Fcll as 41v111_,,arrhtc r Te hmal eta STOP WORK 01'tsliR and a f la,
elf up to $29LOO a dry against the viols He advised T al a copy of Ids stuemcnt may he lbiwm'ded to 11'1e Office of
[lives( l'ahons of the DIA. for insurance eoveragc Vol dlcation.
l do herehV rerhfV lupder the p(trtIs !Tail pe.7Qiie of perjrrrp tit o1, the ilrJorrrrafinrr provided rtbavc rs tare and eorreei.
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issnhyr Authority (ch'S!e one):
L imam or ileauh 2. Building Department 3. C iy1fown (' "k +L Ike-nshtg Board S. Selectmen's Office
6. Other
Contact Person
— Phone A