HomeMy WebLinkAboutCove Construction - 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 than MICHAEL COVE
Doing business as: COVE CONSTRUCTION
P.O. BOX 158
STERLING MA 01564
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 December 31, 2009 unless sooner suspended or revoked.
LICENSE NUMBER: 143
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 Application
LICENSE NUMBER
APPLICANT:
BUSINESS NAME:
MAIL ADDRESS: r
CITYITOWN: '-) �--e r A d ,1(j STATE: ,,A /e ZIP CODE
BUSINESS PHONE: 71 2 �- 'O l e) BUSINESS CELL:
BUSINESS FAX: q 27- q Z.Z=
FEDERAL ID/SS NUMBERa-
LICENSE HELD: Town _ Year Licensed -
LICENSE HELD: Town Year Licensed
LICENSE HELD: Town Year Licensed
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 31 st yearly.
FEE: $ 25.00
SIGNATURE:
DATE: --
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
0 .y
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.
C``-..ri.3 Q 6 ah, `.).`i C
Signature of Individual or Corporat Name By: Corporate Officer (Mandatory, if Applicable)
LO CA
"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:\HealthUane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.moss.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Phone
Are you an emplo er? Cbeck the appropriate box:
Business Type (required):
1. ❑ I am a ployer with _ employees (full and/
5. ❑ Retail
or rt-time).*
6. ❑ Restamant/Bar/Eating Establishment
2. LI y`am a sole proprietor or partnership and have no
y. ❑ Office and/or Sales (incl. real estate, auto, etc.)
`V employees working for me in any capacity.
$• ❑Nop-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
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
I I.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.0 Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box 91 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 Nl.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's
City/State/Zip:
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.
I do hereby eertify,,under the pains mud penalties of perjury that the information provided above is true an( orrect.
Z
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, guwwa
uj
{
7
m
_
�
j
44
7
§
\�§
�
&
/
�
�
-
§
—
§
,
/
Mn
—
�G
°
a
m
NUMBER FEE
08-15 100.00
THE
of snaew
COMMONWEALTH
OF MASSACHUSETTSSSq�H�s�y
TOWN of SHREWSBURY
BOARD of HEALTH
This is to Certify That
MICHAEL COVE/COVE CONSTRUCTION CORP.
7 Crowlev Rd Sterling MA 01564
IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO
CONSTRUCT, ALTER, INSTALL or REPAIR,
Individual Sewage Disposal Systems
This permit is granted in conformity with the State Environmental Code
Table V, Regulation 2.2, and expires December 31, 2008 unless sooner
suspended or revoked.
December 28, 2007
RENEWAL
NUMBER
FEE
$75.00 Pd.
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF HOLDEN
Board of Health
This is to Certify that COVE CONSTRUCTION CORP.
7 CROWLEY RD., PO BOX 158, STERLING, MA 01564
Address
IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO
CONSTRUCT, ALTER, INSTALL or REPAIR,
Individual Sewage Disposal Systems
This permit is granted in conformity with the State Sanitary Code Title V, Regulation 2.2,
and expires July 31, 2009 unless sooner suspended or revoked
License Issued: September 9, 2008
WHITE COPY - Original
YELLOW COPY - Board of Health
PINK COPY - Mailed immediately to
Regional Environmental Engineer,
Department of Environmental
Protection.
1256
ANDREA CRETE
BOARD OF HEALTH AGENT
Holden
Board
of
Health
0±}}p\
®�§to
/)c)
�0
a.cn
O
�_
®
R
�
at LL-
■
2
88co
2
�P
w
wUi
+
:
0
-j
ki
cli
®
§
2&
\
�V)
w
�.
H
§
o/
>
2
\
L�
§q
P
=
CL �
\
w
2
wu
>§
to
22
«
0
$
2
\
7
/
s
2
e
c
.\ f
a
c J
}
0
ƒ�
§
\j
�
/
�oq
2$
�CL�
§
§
ix�k
k�
#
222
2
/
2BE
/
CV)
\
k
_
/
/
40
(
k
a
k
}
\