Disposal Works Installer’s Application
Applicant’s name :
Please submit a copy of 3 previous Installer’s Licenses and Certificate of Liability Insurance and return them to the Board of Health, 250 Main Street, Rutland, MA 01543, with a check (made out to the Town of Rutland) for $210.00 for your Disposal Works Installer’s Permit. Please also complete and return attached forms. Documents may be faxed to 508-886-2929.
If you have any questions, please contact the Board of Health at 508-886-4102. I can also be reached at 978-928-5160.
Thank you for your attention in this matter.
Board of Health Agent
THIS FORM MUST BE RETURNED WITH APPLICATION IN ORDER TO RECEIVE LICENSE.
The Massachusetts Enforcement and Protection Program, Statute 1983, Chapter 233, and the emergency regulations implemented there under by the Commissioner of Revenue, 830 Code of Mass. Regulations 62C.47, require the Town of Rutland to furnish certain information to the Department of Revenue.
Any person, who is applying for a right or license to conduct a profession, trade or business, or for the renewal thereof, must certify under the penalties of perjury upon such application that he has complied with all the laws of the Commonwealth relative to taxes. Said license or renewal may not be issued without such certification.
“Pursuant to M.G.L. Ch. 62C, Sec. 49A, 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.
Social Security Number or Signature of Individual or
Federal Identification # Corporate Name
Date By Corporate Officer
CERTIFICATE OF COMPLIANCE
PROVING COMPLIANCE WITH THE WORKERS’ COMPENSATION ACT
Section 25C of Chapter 152 Massachusetts General Laws requires that every local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the Commonwealth until it has received acceptable evidence of compliance with the Workers’ Compensation insurance coverage required by law.
As a person or company seeking a license or permit to operate a business or to construct buildings, or the renewal of such a license or permit, you must supply one of the following by attaching it to this CERTIFICATE OF COMPLIANCE.
Please check one:
( ) A Certificate of Insurance showing workers’ compensation insurance in effect as of the date upon which the issuance or renewal of a license or permit is requested.
( ) A copy of a policy of workers’ compensation insurance in effect as of the date upon which the issuance or renewal of the license or permit is requested;
In certain circumstances, listed below, workers’ compensation insurance is not required. If one of the situations applies to you, please check off the appropriate exemption and sign the statement where indicated before a Notary Public, who will then notarize the sworn statement.
COMMONWEALTH OF MASSACHUSETTS)
COUNTY OF WORCESTER ) SS.
( ) I am self-employed and have no employees who work for me, and do all of the work of my business, named _______________________________at ___________________________, myself. Therefore, I am not required to obtain workers’ compensation insurance.
( ) I and __________________________________are the owners of the business named
_________________________________________, at ___________________________________
and we do all of the work of this business ourselves, and have no employees. Therefore, we are not required to obtain workers’ compensation insurance.
I certify that the above is true and correct under the pains and penalties of perjury this
___________________day of ________________________.
STATE/COMMONWEALTH OF _______________________________
ON THIS ___________DAY OF ____________, 20__, BEFORE ME, THE UNDERSIGNED NOTARY PUBLIC, PERSONALLY APPEARED ____________________________, PROVED TO ME THROUGH SATISFACTORY EVIDENCE OF IDENTIFICATION, BEING, __________DRIVERS LICENSE, TO BE THE PERSON WHOSE NAME IS SIGNED ABOVE, AND ACKNOWLEDGED THE FOREGOING TO BE SIGNED BY HIM/HER VOLUNTARILY FOR ITS STATED PURPOSE.
COMMISSION EXPIRES _________________
QUALIFIED IN STATE/COMMONWEALTH_____________