HomeMy WebLinkAboutBarrows Contracting - 12/31/2009Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Disposal Works Installer's Permit
This is to certify that., WILLIAM BARROWS
Doing business as: BARROWS CONTRACTING
519 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 the STATE ENVIRONMENTAL CODE: 310 CMR
15.02(2) and expires December31, 2009 unless sooner suspended or revoked.
LICENSE NUMBER: 6
FEE : $25.00
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Disposal Works Installer
LICENSE NUMBER
6
APPLICANT:
WILLIAM BARROWS
BUSINESS NAME:
BARROWS CONTRACTING
MAIL ADDRESS:
519 GILBERT ST
CITY/TOWN: MANSFIELD STATE: MA
BUSINESS PHONE: (508) 339-7432 BUSINESS CELL:
BUSINESS FAX:
FEDERAL ID/SS NUMBER 04-2650425
OCT, 2 8 2008 D
ZIP CODE 02048
LICENSE HELD: Town
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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 Satndards for the Subsurface Disposal of Sanitary Sewage".
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires December 31st yearly.
FEE: $ 25.00
SIGNATURE:
DATE:
/dl e
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
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 I ividual
Corporate me (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
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** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
: Boston, MA 02111
nvww.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: AIVZOW5 f'A17n)3e'7)V walwAq :;"� /dti'm's L"t
Address: 577 6110e.117 -S 7
City/State/Zip: k�06 ,51:jl lt)) �%4 Phone #: ® ® sue/ 7q3
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with employees (full and/
5. ❑ Retail
9r part-time).*
VI
6. ❑ Restaurant/Bar/Eating Establishment
2. am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (me]. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
[No workers' comp. insurance required]
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]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' corance crimp. insureq.]
12.N-6ther 05X'rALf47nA16 646 n,7Yl +%76 ✓)
*Any applicant that checks box #1 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 mry employees. Below is the policy information.
Insurance Company Name: ( RdN17r .7/tZr �IC✓64i90e r eg
Insurer's Address: 3� WoW 1*1(6ty 80
City/State/Zip: _1 ,t9R,5
Policy # or Self -ins. Lic.
Expiration
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.
/ do hereby certify, undeel # nd penalties ofperjury that the information provided above is true and correct.
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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 Person: Phone #:
www.mass.gov/dia