HomeMy WebLinkAboutPisano General Contracting Corp. - 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 JOHN PISANO
Doing business as: PISANO GENERAL CONTRACTING CORP.
8 NORTH WHITE PINE LANE
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: 60
FEE : $25.00
BOARD OF HEALTH
Dr. Ra and Martin, Chairman
Town of Mansfield - Board of Health
Disposal Works Installer Application
LICENSE NUMBER 60
APPLICANT: JOHN PISANO
BUSINESS NAME: PISANO GENERAL CONTRACTING CORP.
MAIL ADDRESS: 8 NORTH WHITE PINE LANE
Town of Mansfield
6 Park Row
Mansfield, MA 02048
CITY/TOWN: MANSFIELD STATE: MA ZIP CODE 02048
BUSINESS PHONE: (508) 326-5189 BUSINESS CELL:
BUSINESS FAX:
FEDERAL ID/SS NUMBER 016-58-4712
LICENSE HELD: Town Year Licensed
LICENSE HELD: Town
LICENSE HELD: Town
Year Licensed
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
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: rp olrate Officer randatory, if applicable)
0A-, P) i i 19/AD,
** 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 Contntonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf tvIvmmassgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Address:
City/State/Zip:
Phone #:
Are�yo an employer? Check the appropriate box:
Business Type (required):
1.i " 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
T ❑ Office and/or Sales (met. 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 1
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
1
with no employees. [No workers' comp. insurance req.]
12.0 Other
`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 #l.
I am an employer that is
Insurance Company Nam
' compensation insurance for my employees. Below is the policy information.
Insurer's Address: /S �� �, b rcx c '7 4.
City/State/Zip:
Policy # or Self -ins. Lic. # �& ) c u1 (^sr) Expiration Date:
v
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 ilgainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatioils of the A for insurance coverage verification.
I do hereby cVr4fy, u�4er the pains and pent?1tt' ss ofperjury that the information
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
true and correct.
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.inass.gov/dia