2014 SEPTIC HAULER-STEWART'S SEPTIC SERVICE Commonwealth of, iia >tusetfs}
City of Saleni
Board of$ealth 10 b6dey Driscoll.,
120 VWasgton Street,4th Floor' Mayor
s - , s �-.
:SALEM,MA 01970
�ept�e Haulers Permit
_ -
DATE PM' TED.i 02/27/2014
ESTABLISHMENT NAME;. Stewarts Septic Service
File Number:s1IF2007-000037. J&S:;Developmeni l
58 So Kuritiall Street
BRADFORD MA 0183-5
IL
LOCATED AT
SA�LEK MA 0I9'TU'
Per* T e _ Permit No. Pernat Issaed pl r F Aires, Fee Restrictions/Notes
_ -.
SEPTIC HAULER BHP201403Z..3, ,Ian-1 20`14 Dec 31,;2014 $105 00 V_EIIICLE TYPE:Vaeuin Primp
g`F. TruckReg##6490
Total Fees: S 05, ,
PERMIT EXPIItES. s ecemb�r 31,2014
Board of Health
Page 1.
CITY OF SALEM, MASSACHUSETTS IV
BOARD OF HEALTH
120 WASHINGTON STREET 4"'FLOOR P�ib1lCHealtll
, Prevent,Promote,Protect,
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin a,salem.com
LARRY RAnU-)IN,RS/REIIS,CFIO,CP-FS
MAYOR HEtILTH AGENT
APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES
FEE: $105 Per Vehicle payable to the City of Salem No Cash
� \r
Name of Applicant: n C. 4 j 1n �/pV `nC'�?.1'•1 //����
Address: (ca 1 1 Ss 1 l 1 1 M A /I I � � Ah!( A P
Name of Company: J A r�.S Dc)u P_1 L,)M ; r t" 3 B J ltn_ Wit£
Address:_55�_ '3n }'S 1 rT) L)o I � 51- 3,(Pd q✓G l{ 0/4e 71
Email Addre j U ha ,21G 1 141-12X r 1
Type of Vehicle �..
Gross Weight
Reg.# �� Year of Maki
Substance(s)Hauled r
Route of Travel U C �'1�"9- I�}'1/.2 ,
(must be completed)
Schedule of Travel Let
I HAVE READ THE BOARD OF HEALTH REGULATIONS,"RULES AND REGULATIONS FOR TRANSPORTIING OFFENSIVE
SUBSTANCES."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I
UNDERSTAND THEM;AGREE TO ABIDE BY THEM AND UNDERSTAN THAT FAILURE TO DO SO MAY RESULT IN
REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES.
PURSUANT TO HGL C62C,S49A I CERTIFY UNDER THE PENALITIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND
BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER THE LAW.
I", -I. , 7, 10?51� �
�ql�j
Si ure �' Date SS#or Federa ID#
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Permit# Check# Check Date /-i ?�5,5 '
Updated 11/20/13 p
w
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lityes�igations
kvi 600 Tl6 ingi��Street
Boslan,W"011r
www,mass.gov/dia
Workers' Compensation InsurariCe Affidavit: General Businesses
Applicant Information
Please Print Le.
aibly
.F
Business/Organization Name: 10,
Address: I YYlsi..
City/StatelZip: jYr:� Q 1�35 Phone
irGiG�
Are you an employer?Check the appropriate box: BtisMess-Type(required):
1.❑ I'am a employer with employees(full arid/ '5. [].Retailor part=tim.e).* 6.': Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have.no
employees working for mein any capacity. 7. ❑ Office and/or Sales (incl.real estate,auto,etc.)
[No.woikers' comp. insurance required] 8: ❑Non-profit
3.❑ 'We are a.corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4);and we have 10.0,Manufacttuing
no'employees. [No workers' comp.insurance required]*
4.❑ We are a non-profit organization,"'staffed by.volunteers, I U Health Care.
with no employees. [No workers' comp.insurance ieq.] 1219`bther
*Any applicant that checks box#1 must also rill out-the section below showing their workers'compensation policy information.
**If the corporate cf icers Have exempted themselves,.but the corporation has other employees,a workers'compcnsmon policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address: e 'C'
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 maybe forwarded to the Office of
Investigations of the DIA.for insurance coverage verification.
I do hereby cert' , under t. pains artd penalties ofper�'ury that the information provi ove ' tru nd correch
Si attire: / 1 f> t'
V Date:
Phone#:.
Offtcial use only. Do not write in this.area,to be completed by.ci6.or town official
City or Town: PiflLiceits@#
Issuing Authority(circle one):
1.Board of Health 2.Buildmg Department 3. City/Town Clerk 4.Li
6.'Other censing Board' S.Selectmen's Office
Contact Person: Phone#:
Nvwi :mass:gov/dia