HomeMy WebLinkAboutPodgurski Corp. -12/31/2009This is to certify that:
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Hauler's Permit
P. CHRISTOPHER PODGURSKI
PODGURSKI CORPORATION
8 SPRINGDALE AVENUE
CANTON, MA 02021
PERMIT No: 1
is hereby granted a permit for a HAULER. This permit is granted in conformity with the Statues
and Ordinances relating thereto, and expires December 31, 2009 unless suspended or revoked.
REGISTRATION No: L37481
FEE PER TRUCK: $60.00
BOARD OF HEALTH
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Dr. Raymond Martin, Chairman
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Town of Mansfield - Board of Health
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. AS A
Hauler's Application
BUSINESS NAME:
BUSINESS ADDRESS
TOWN / STATE / ZIP:
NAME OF OWNER:
TELEPHONE No:
CELL No:
FAX No:
FED ID/SS No:
REGISTRATION No:
No OF TRUCK(S):
FEE PER TRUCK:
SIGNATURE:
V
Town -of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER: r
TOTAL FEE: r$50.00
PODGURSKI CORPORATION
8 SPRINGDALE AVENUE
CANTON, MA 02021
P. CHRISTOPHER PODGURSKI
(781)828-0821
(781)828-0438
04-3187005
L37481
1
$50.00
Permit Expires December 31st yearly.
DATE:
Please make appropriate changes. Sign, date and enclose check 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.
Sigftaty.ee of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
0Li-3)�'-- --)w-S
** 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
UlfDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wrviv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address:
f`y�A C`2/ 7 Phone#:
Are you au employer? Check the appropriate box:
Business Type (required):
IA�I am a employer with _Sj employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ 1 am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (inel. 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
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
I LF] Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.❑ Other
*Any applicant that checks box # I must also fill out the section below showing (heir 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 41.
Into 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. Lie. #
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 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 wfr e par and penes of perjury that the information provided above is true and correct.
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.gov/dia
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Hauler's Permit
PERMIT No: 5
This is to certify that:
MICHAEL & CAROLYN MOWBRA
WASTE SOLUTIONS, INC
965 PLAIN ST
MARSHFIELD, MA 02050
is hereby granted a permit for a HAULER. This permit is granted in conformity with the Statues
and Ordinances relating thereto, and expires December 31, 2009 unless suspended or revoked.
REGISTRATION No: #53427
FEE PER TRUCK: $50.00
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
94t�.5HG
Town of Mansfield - Board of Health
9h t4'
Hauler's Application
Town of Mansfield
6 Park Row
Mansfield, MA 02048
(j)
AIM
PERMIT NUMBER: 5
TOTAL FEE: $50.00
BUSINESS NAME: WASTE SOLUTIONS, INC
BUSINESS ADDRESS 965 PLAIN ST
TOWN I STATE / ZIP: MARSHFIELD, MA 02050
NAME OF OWNER: MICHAEL & CAROLYN MOWBRA
TELEPHONE No: (781) 834-7007
CELL No:
FAX No:
781) 834-0004
FED ID/SS No:
04-3214735
REGISTRATION No:
#53427
No OF TRUCK(S):
1
FEE PER TRUCK: $60.00
Permit Expires December 31st yearly.
SIGNATURE: s may' — DATE: /, ' ,�;if 4
Please make appropriate changes. Sign, date and enclose check 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.
e
* Signature o Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
S ✓``f
** 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
Ulf
Boston, MA 02111
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: A,L,= JC✓/?i /�.
Address: l /i%✓
City/State/Zip: AX /' e'5 0 Phone #: 4 0 1," X %C
Are you an employer? Check the appropriate box:
Business Type (required):
1..ELI 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 (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
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ 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 #I 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 rrl.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: ci% ,,e, //
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. # / % r % ) 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 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, under the pains out penalfies�o perjury that the information provided above is true and correct.
1 , i7
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
Phone
www.mass.gov/dia