HomeMy WebLinkAboutDeJonco Construction -12/31/2008COMMONWEALTH OF MASSACHUSETTS
TOWN OF MANSFIELD
SIX PARK ROW, MANSFIELD, MA 02048
DISPOSAL WORKS INSTALLER'S PERMIT
This is to certify that:
doing business as:
ROBERT DEMANTINO
DEJONCO CONSTRUCTION
PO BOX 1277
MANSFIELD, MA 02048
is hereby granted a DISPOSAL WORKS 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: 10
Fee: $25.00
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
DISPOSAL WORKS INSTALLER APPLICATION
LIC: 10
APPLICANT: ROBERT DEMANTINO
BUSINESS NAME: DEJONCO CONSTRUCTION
MAIL ADDRESS: PO BOX 1277
TOWN: MANSFIELD STATE: MA ZIP CODE: 02048
BUSINESS PHONE: (508) 339-2800
FAX NUMBER: �bO o-)-Czl - -7 9
FED ID/SS NO.: O L/-�)
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 3ISt yearly
Fee: $25.00
SIGNATURE:
DATE: / - J(ot Q �
Please make appropriate changes. Sign, date and enclose check for $25.00 payable to Town
of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA
02048.
R ftalthVmte's D.cu.ew,\PEWIT APPLICATIONSVNSTALLERSAc
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name
**Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
R:\Healthllan&s Documents\PERMIT APPLICATIONSJAX CERTIFICATION FORM.doc
The Contmonivealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf wivw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Ledbly
Business/Organization Name: Dl5,T Old C U Cyln6 Co g0
Address: P 6 60 'Y
City/State/Zip: glTo> Sjtr51 4=Li4 9//� � G
#: ,lpr-33i—,;$Y00
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. ❑ Restauram/Bar/Eating Establishment
2. ❑
I 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.
8• Non-profit
3. ❑
[No workers' comp. insurance required]
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]**1
l.❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
12.❑ Other(l',,n
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box # 1 must also fill out the section below Showing their worKers compensation poucy nomination.
**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 nay eat loyees. Below is the policy information,.{
Insurance Company Name: � as 0iQ ^II( v ti— S('T—^ <4 — g— I ^ L
Insurer's Address: p
City/State/Zip:pe4A CAf..i1 64->j 4Z 4
Policy # or Self -ins. Lic. # _ Z Expiration Date: —
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
I,
ine 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, tin deetthjee ainsnnd penal ies of perjury that the information provided above is true and correct
not,. L —�
M
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
%vww.mass.gonma
Phone