HomeMy WebLinkAboutB-P Trucking - 12/31/2008This is to certify that:
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
HAULER'S PERMIT
B-P TRUCKING, INC.
P.O. Box 386
ASHLAND, MA 01721
is hereby granted a permit for a HAULER. This permit is granted inconformity with the Statues
and Ordinances relating thereto, and expires December 31, 2008, unless suspended or revoked.
Fee per Truck: $50
Registration N. o: 11174
Permit No.: 2
I.17:771 11 ,IDI\NYII
.�-
Dr. Raymond Martin, Chairman
BUSINESS NAME:
BUSINESS ADDRESS:
TOWN & ZIP:
NAME OF OWNER:
TELEPHONE NO:
FAX NO:
REG. NO.:
FED ID/SS NO.:
PERMIT NO2
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
HAULER'S APPLICATION
B-P Trucking, Inc.
P.O. Box 386
Ashland, MA 01721
Joseph DePaolo
508-231-1000
508-881-6123
11174
04-2595703
FEE PER TRUCK. $50.00
Permit Expires December 3 1 " yearly.
SIGNATURE:
DATE: Or ► : -- n "q- n 7
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.
R:V e.hhVnne s DOCWnents\PERMIT APPLICATIONSUTAULER'S doe
TAX CERTIFICATION FORM
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.
Ili— iP
Signature of Individual or Corporate Name By: rp •ate Officer (Mandatory, if Applicable)
Ov a 9s7oa
**Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this 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 Massachusetts General Law
Chapter 62C, section 49A.
R:\HeallhVaa&s Documents\PERMIT APPLICATIONMAX CERTIFICATION FORM.doc
name; B—P Truckin Inc.
city Ashland slate: Ma av 01721 nbone# 508-231-1000
I am a sole proprietor and have no one Business Type: ❑ Retail
working in any capacity. ❑ Office
I am an em ]oyer with 50 employees (full & art time . ❑ Other
I am an employer providing workers' compensation for my employees
compsnvnnme• B—P Trucking; Inc.
P 0 Box 386
Restaurant/Bar/Eating Establishment
Sales (including Real Estate, Autos etc.)
on this job.
city Ashland Ma 01721 pi one #: 508-231-1000
insprance co. CNA Ins.. Co poll #11
- "
I am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices:
coin on* name:
city phone M _ ..
eel an name:
city .. phone #. . .
Fallme to secure coverage as required under Section 25A of MGL 152 ran lead to the imposition of criminal penalties of a flee up to SI,500.00 and/or
one yeah' imprisomnent as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against ma I undentand that ■
copy of this statement may be forwarded to the Off -ice of Investigations of the DIA for coverage verification
7 do hereby
that the inform anion provided above is true and correct
oMetal use only do not write in this arts to be completed by city or town official
city or town:
❑ cbeck if immedinu response is required
contact person:
(reused SWL 2103)
:# 508-231-1000
pernvt/liceme p ❑Building Department
❑Licensing Board
❑Selectmen's Office
❑Health Department
phone H; ❑Other