HomeMy WebLinkAboutDonald Ploof - 12/31/2008COMMONWEALTH OF MASSACHUSETTS p
TOWN OF MANSFIELD V
SIX PARK ROW, MANSFIELD, MA 02048
DISPOSAL WORKS INSTALLER'S PERMIT
This is to certify that:
doing business as:
DONALD PLOOF
330 GILBERT STREET
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: 141
Fee: $25.00
BOARD OF HEALTH
Ll-~
Dr. R and Martin, Chairman _
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
DISPOSAL WORKS INSTALLER APPLICATION
LIC:
APPLICANT: Derm 43 j
MAIL ADDRESS: 3 3 0 G-t l h,�, h
TOWN: �� �t t� STATE:/ ZIP CODE:
BUSINESS PHONE: a fir-' 3 3 a _7 4 F"
FAX NUMBE
FED ID/SS NO.: /iP,JJ&')
LICENSE HELD: Town Wearlicensed
i 4;
LICENSE HELD: Town Year licensed
LICENSE HELD: Town Year licensed
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 fiom them may be cause for revocation of this
permit.
Permit Expires December 31 st yearly
Fee: $25.00
SIGNATURE:
DATE: 7 -
Please make appropriate changes. Sign, date and enclose checkfor $25.00 payable to Town
of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA
02048.
R U eaRhVane's OoaimmnsNERMIT APPLICATIONSBLANK INSTALLERS.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office 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 N
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inel. 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, 11.0 Hceajth C[�re
with no employees. [No workers' comp. insurance req.] 12. Other Cr lyc
*Any applicant that checks box #1 must also fill out the section below shoving dieir 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 ann an employer that is providing rporkers' compensation insurance for my employees. Belowlsoapollryinforination.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. #
Attach a copy of the workers'
Expiration
policy declaration page (showing the policy number and expiration date).
Failure to secure coverag"s required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00a,,Wor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 aA y 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, nn er, to pains and penalties of perjury that the information provider/ above is trite and correct.
I fi r a*P 7- 0
Phone #: 575 �--3 i !2 D`03�y—
Official use only. Do not rprite 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 Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia
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 In victual or Corporate Name
G"
"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:\HealthVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc