HomeMy WebLinkAboutDeJonco Construction - 12/31/2009Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Disposal Works Installer's Permit
This is to certify that: ROBERT DEMANTINO
Doing business as: DEJONCO CONSTRUCTION
PO BOX 1277
MANSFIELD MA 02048
Town of Mansfield
6 Park Row
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 December 31, 2009 unless sooner suspended or revoked.
LICENSE NUMBER: 10
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
10
APPLICANT:
ROBERT DEMANTINO
BUSINESS NAME:
DEJONCO CONSTRUCTION
MAIL ADDRESS:
PO BOX 1277
CITY/TOWN: MANSFIELD
BUSINESS PHONE:
(508) 339-2800
BUSINESS FAX:
(508) 261-7855
FEDERAL ID/SS NUMBER 04-3207232
LICENSE HELD: Town
STATE: MA ZIP CODE 02048
BUSINESS CELL: (508) 294-2101
Year Licensed
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 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
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 (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
0V'3_ Ac d
* 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.
11/18/2008 TVH 11:40 FAX
0001/002
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfJlee of Investigations
600 Washington Street
Boston, MA 02111
www,mass,gov/dia
Workers' Compensation Insurance Affidavit; General Businesses
Applicant Information Please Print Lete blv
Business/Organization Name: C
Address: ) �-, SIC
Are you an employer? Check the appropriate box:
I. ❑ 1 am a employer with employees (full and/
or parwime)."
2. ❑ 1 am a sole proprietor or parmership and have no
employees working for me in any capacity.
[No workers' camp, insurance required)
We are a corporation and its onicors have exercised
their right of exemption per c. 152, § I(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We arc a non-profit organization, stalled by volunteers,
with no employees. [No workers' comp, insurance req.]
Phone #: < S % dd6&
Business Type (required):
S. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, elite, etc.)
8, E] Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
) LEJ Health Can:
12.0 Other,_
'Any applicant that checks box el must also fill out the section below showing their warkem' compensation policy Intotmanon.
'if the corporate officers have exempted themselves, but the corporation has other emptoyea, a workers' compensation policy is required and such"
organlretian ahould check box el.
am an employer that is providing workers' compensallon Insurance for my employees. Below is file Polley information,
Insurance Company Name:
Insurer's Address:___
City/Stale/Zip:
Policy 0 or Soil' ins. Lic.
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 MOL 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 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.
hereby ceryfy, under
of perjury that the information provided above Is true
Official use only, Do not write /a this area, to be completed by city or town oJrciat
City or Town:
Permit/License
Issuing Authority (circle one):
I, Board of Health 2, Building Department 3, City/Town Clark 4, Licensing Board S. Selectmen's Office
6.Other
Phone
www.mus.gov/0la