2013 SEPTIC HAULER-WAYNE'S DRAINS Commonwealth of Massachusetts
+� City of Salem
Board,of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Septic Haulers Permit
DATE PRINTED: 11/30/2012
ESTABLISHMENT NAME: _ Waynes Drains
File Number:SHF-2006-000006 P.-O.BOX 298
WILMINGTON MA 01887
LOCATED AT:
SALIENT, MA 01970
Permit Type Permit No. Permit.Issued ^'Permit Expires Fee Restrictions/Notes
SEPTIC HAULER 6HP-2013-0058 Jan 1,2013 Dee 3-1,2013 $105.00 Vehicle type International 7600-
2007 Reg M79896.
Total Fees: $105.00`
PERMIT EXPIRES IDecember 31, 2013
Board of Health
Page 1
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CITY OF SALEM9 MASSACHUSETTS
��.� BOARD OF HEALTH
120 Wt1SHINGTON STREET 4. FLOOR Pub]HcHealth
Prevent,Promote.Protect.
TEL. (978) 741-1800 FAX(978) 745-0343
KIMBERLEYDRISCOLL lramdin u salem.com
I,r1RRY RA1`V0IN,I2S/RGI-IS,CI-[O,CP-FS
MAYOR FIEALTI-I 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:
Name of Company: Ua, �3Z 1 C�► . `�G , � P X 7 Address: n # --
ZT 3l�
Type of Vehicle -n 'm1Gl.fi wa
Gross Weight_ as �j_
Reg.#- M ((A — �n Co Year of Make:_ Q[j
Substance(s)Hauled
Route of Travel Lcxj--)�� 1 -5-17 V-� IG N-,cAe, r M
(must be completed)
Schedule of Travel- Q r-yq — QM
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.
Cl\ --Vth �
r 1 �-► z a r U-1
Signs ure Date SS#or Federal ID#
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------
Permit# Check# Check Date
Updated 5/23/11
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:. 2..
City/State/Zip: ( I?Rj Phone
Are you an employer?Check the appropriate box: Business Type(required):
1. I 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(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' 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.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp, insurance req.] 12.X Other ° cc)t ►�C9i'+
- � .
*Any applicant that checks box#1 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#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: l __
Insurer's Address:
City/State/Zip: �, Vie^ 4 , y
Policy#or Self-ins.Lic.# �N�� �Z 7 5-1 CC) Expiration Date: :Z
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 here y c ',y,under the pains and penalties of perjury that the information provided above is true and correct
Siunature: . Date:
Phone#: 7a I .- �: i c d
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