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2014 SEPTIC HAULER-WAYNE'S DRAINS - 5• f - k, g Commonwealth of Massachusetts City of Salem - r "'Board of Healthy " " (Gmberley Driscoll 120 W ashington Strael,4th Floor Ma . BALEIVI,MA".019'70 _ - �A p _ , _ SepticIau�� erm�t DATE PIMTED 012IM14, ESTABLISHMENT NAMES: "Waynes Drains T.File Ntimber,BBF-2,006-Q00006 W A99GTON MA 0:1887 LOCATED AT . E. SALEM,'MA: 0197D' - r Permit Type..- Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SEPTIC IfAULER BHP4014-0374 ran.1,,2014 °Dec 31,_2014 ' $t05.00 ''ehicle-type International 7600- K 2007 Reg M79996. TOW liees $10500` PER�►�EXPIRES, ecember 31, 2Q14. Baaird of-Health z Page 1 L-F.� CITY OF SALEM MASSACHUSETTS 10 BOARD OF HEALTH 120 WASHINGTON STREET 4T'�'FLOOR PublicHealth Prevent.Promote.Protect. TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL lramdin a salem.com LARRY RAMDIN,RS/RL:I IS,CIIO,CP-FS MAYOR HEM TH AGENT APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $105 Per Vehicle payable to the City of Salem No Cash Name of Applicant: Address:Q(D b14S. Name of Company: -1 r� �T ! ©r r Te#: �� Address: q Email Address IL& a� Ric)L• L�:r�'1 Type of Vehicle +�` �`(1( � Gross Weight, 7 cL� Reg.# M fl q , A�® Year of Make: Substance(s)Hauled 0t Route of Travel otuip c (must be completed) Schedule of Travel �Ei C)Q -cc zx) . 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. Signature Date SS#or Federal ID# "� ----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----------- Permit# Check# Check Date -j Updated 11/20/13 �v� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 10 1 Congress Street, Suite 100 y Boston,MA 02114-2017 �n �Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARnlicant Information Please Print Legibly Name (Business/Organization/Individual): Wayne's Drains Inc Address:P.O. Box 298 City/State/Zip:Wilmington, MA. 01887 Phone#:781-272-3100 Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 19 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P n'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no Drain&Pumping Services employees. [No workers' 13.0 Other P 9 comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. '+Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Wesco Insurance Company Policy#or Self-ins. Lic.#:WWC3065530 Expiration Date:08/18/2014 Job Site Address: City/State/Zip: 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 her y ce ray under the pains anj penalties of perjury that the information provided above is true and correct. Sig*nature: Date: \ 1 r Phone#: ` 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. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: