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Home My WebLink AboutMRJ Enterprises, Inc. - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Disposal Works Installer's]), J This is to certify that: FRANCIS TEES Doing business as: MRJ ENTERPRISES, INC. 201 PLYMOUTH STREET MIDDLEBORO, MA 02346 is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or repair individual sewage disposal systems. This permit is granted inconformity with the STATE ENVIRONMENTAL CODE. 310 CMR 15.02(2) and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 129 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 129 f ii� 6001 C 0 APPLICANT: FRANCIS TEES BUSINESS NAME: MRJ ENTERPRISES, INC.-- MAIL ADDRESS: 201 PLYMOUTH STREET CITYITOWN: MIDDLEBORO STATE: MA ZIP CODE 02346 BUSINESS PHONE: (508) 946-6044 BUSINESS CELL: BUSINESS FAX: (508) 946-5640 FEDERAL ID/SS NUMBER 043 300 241 LICENSE HELD: Town _ /A/11/ y✓d ///UiO LICENSE HELD: Town LICENSE HELD: Town /?/, *le- � oI^e7 Year Licensed Year Licensed0�� 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: / 'a O -olf 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. %Ylla T �rJi�el- gg S �� * Signature of Indi idual or Corporate Name (Mandatory) ///6d� � By: Corporate Officer (Mandatory, if applicable) G y 3 30D�yJ ** 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 Ulf wwruutass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: City/State/Zip: �8Xe)1-6 lj / Phone S Are you an employer? Check the appropriate box: Business Type (required): L N I am a employer with �_ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/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. ❑Nop-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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.N Other 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 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 #I. I out an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1(&V6to cmuoul t " s tin Q Insurer's Address: PO boy 9103 City/State/Zip: WIb d D A jA A CYs D9r) Policy # or Self -ins. Lie. #_AL R jt th - 3 cj_9 li q to — c - ()% Expiration Date: R -1 - D 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 certify, tinder the pains and penalties ofperjuty that the information provided above t. is true and correct. sa� Signature � /'� 1.fsc� /i.. a /0. w Date: Z -.g6 _e,9 Phnne ik 1v 07� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit7License # 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.gowara TRAVELERSJW WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (XACRUB-397H986-5-08) RENEWAL OF (XOUB-397H986-5-07) INSURER: TRAVELERS CASUALTY AND SURETY COMPANY INSURED: MRJ ENTERPRISE, INC. 201 PLYMOUTH STREET MIDDLEBORO MA 02346 Insured Is A CORPORATION NCCI CO CODE: 11223 PRODUCER: PREFERRED INS AGENCY INC 10 NEW ENGLAND BUS CTR DR STE 303 ANDOVER MA 01810 Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-14-08 to 08-14-09 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA NY B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV OK OR PA RI SC SO TN TX UT VA VT WI D. This policy includes these endorsements and'schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 07-28-08 NM OFFICE: NAT'L PRGM'S-ORL 715 PRODUCER: PREFERRED INS AGENCY INC 00715 007921 DIRECT BILL