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HomeMy WebLinkAboutUnique Builders 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: DOMENIC LANZILLO Doing business as: UNIQUE BUILDERS CORP 90 CENTRAL STREET FOXBORO MA 02035 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: 128 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 128 APPLICANT: DOMENIC LANZILLO BUSINESS NAME: UNIQUE BUILDERS CORP MAIL ADDRESS: 90 CENTRAL STREET CITY/TOWN: FOXBORO STATE: MA BUSINESS PHONE: (781) 953-7811 BUSINESS CELL: BUSINESS FAX: (508) 698-2622 FEDERAL IDISS NUMBER 015-64-7616 ZIP CODE 02035 LICENSE HELD: Town 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) n A -�- By: Corporate Officer (Mandatory, if applicable) 6315 G 6/- �� '( 6 ** 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. I LULL-ZUU-:` MUN Ulf:Ji ***************** *** TX REPORT *** ***************** JOB NO. 0148 DEPT. ID 504 ST. TIME 12/22 08:37 PGS. 3 SEND DOCUMENT NAME TX/RX INCOMPLETE ----- TRANSACTION OK 915086982622 ERROR ----- FAX COVER SHEET Town of Mansfield Board of Health DATE: DECEMBER 22, 2008 TIME: 8:30 am FROM: Town of Mansfield Board of Health Phone: 508-261-7366 Six Park Row Fax: 508-261-7343 Mansfield, MA 02048 TO: DOMENIC LANZILLA FAX ff: 508-698-2622 Type of Form: Number of Pages: 3 (Including this sheet) if you do not receive all of the above pages, contact the Mansfield Board of Health. MESSAGE: PLEASE RETURN WITH ORIGINAL SIGNATURES. THANKS. 12/14/2z0000821:51MON 8:385086a980522 UNIQUE BUILDERS PAGE 02/02 f�j092/093 The Conuw tnwealth ofMassachttsens Department of InditstpialAccidents Off?ae of Investigations 600 Washington Street Boston, KA 02111 Ivunv.inass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apirlicntrt ini'ormation / Please Print LeLA Business/Organization Name: I ( ) i n, ,o {fit I r lriA llc 1 r 'A Are you an employer? Check the approprinto box: L ❑ I am a employer with employees (full and/ or part-time),* 2. ❑ I Am a sole proprietor or partnership and have no employees working for me in any capacity, �-t � [No workers' comp. insurance required] 3.0, we arc a corporation and its officers have oxcreised their right of exemption per c, 152, § 1(4), and we have no employees. (No work -ors' comp. insurance required]* 4. © We are a non-profit organization, staffed by volunteers, with no employees, [No workers' comp, insurance req,I Phone Business Type (required); 5, El Retail 6. ❑ Restaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (inel, real estate, auto, etc,) 8, ❑Notrproflt 9. ❑ Entertainment 10. ❑ Manufacturing I l.❑ health Carc 1-).❑ other -Any applicant Chat cheeks box lit must also GII out ilia section below showing ncCiT workers' compensation policy inronnation. e"IfCho wepurateoff curs have exempted themselves, but the corporstlon has othoromployow, A workers' cpmpansaiion pulicy is ,gamed And such an organization should clack box Al. - 1 am an employer that rs providing workers' compenvoilon hasurance for thy employees, Below in the policy information insuramo Company Name: Insurer's Address: City/State/Zip: Policy # or,Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number kind expiration date), Failure to becure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties ora Me up to $t,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER slid a fine of up to W50,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification, the pains and penalties vfpgrjyry Drat The, informotlon provided above is irae Official rise only. Do not write in this area, to be completed by city or town official Cityor Town; Pormit(Licensc Issuing Authority (circle one)! t. Board of Health 2. Building Department 3..0ty/rawn Clerk 4. Licensing Board 5, Selectmen's Office 6. Other Contact Persont Phone 12/14/2008 21:51 5086980522 UNIQUE BUILDERS PAGE 01/02 LeL� OC,4-,OA-( Q--- UP', c) u e &t ld.2/-S FAX COVER SHEET Town of Mansfield Board of Health DATE: JANUARY 13, 2009 TIME: 9:30 am FROM: Town of Mansfield Board of Health Six Park Row Mansfield, MA 02048 TO: DOMENIC LANZILLA FAX #: 508-698-2622 Type of Form: Phone: 508-261-7366 Fax: 508-261-7343 Number of Pages: 3 (Including this sheet) If you do not receive all of the above pages, contact the Mansfield Board of Health. MESSAGE: PLEASE FILL OUT ENCLOSED PAPERWORK AND RETURN WITH ORIGINAL SIGNATURES. WE CAN NOT ACCEPT FAXED COPIES. THIS IS A STATE LAW AND WE CAN NOT PROCESS YOUR APPLICATION WITHOUT ORIGINAL SIGNATURES. THANKS. 01/13/2009 TUE 09:34 iR3570 U001 *** TX REPORT *** JOB NO. 0164 DEPT. ID 504 ST. TIME 01/13 09:31 PGS. 3 SEND DOCUMENT NAME TX/RX INCOMPLETE ----- TRANSACTION OR 915086982622 ERROR ----- FAX COVER SHEET Town of Mansfield Board of Health DATE: JANUARY 13, 2009 TIME: 9:30 am FROM: Town of Mansfield Board of Health Six Park Row Mansfield, MA 02048 TO: DOMENIC LANZILLA FAX #: 508-698-2622 Type of Form: Phone: 508-261-7366 Fax: 508-261-7343 Number of Pages: 3 (Ierctutliiig thi, she0t) If you do not receive all of the above pages, contact the Mansfield Board of Health. MESSAGE: PLEASE FILL OUT ENCLOSED PAPERWORK AND RETURN WITH ORIGINAL SIGNATURES. WE CAN NOT ACCEPT FAXED COPIES, THIS IS A STATE LAW AND WE CAN NOT PROCESS YOUR APPLICATION WITHOUT ORIGINAL SIGNATURES. THANKS.