Disposal Works Installer's Application
                               
        

                                                   TOWN OF RUTLAND

                                          MASSACHUSETTS

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BOARD OF HEALTH
 250 MAIN STREET
RUTLAND, MA 01543

        
                         Disposal Works Installer’s Application


Applicant’s name      :     


Please submit a copy of 3 Installer’s Licenses from other Towns/Cities if you have not been licensed with the Town previously. Please forward a 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 $240.00 for your 2016 Disposal Works Installer’s Permit. Please also complete and return attached forms. Documents may be faxed to 508-886-2929.

Please also provide a telephone number where you can be reached.
  
If you have any questions, please contact the Board of Health office at 508-886-4102 or boh@townofrutland.org. I can also be reached at 978-928-5160.

Thank you for your attention in this matter.

                                                Respectfully,

                                                

                                                Randy Mizereck
                                                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
(if applicable)

















                                        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_______________________________.
                                                                                                                                                 

                                                                                                                                                                                 _______________________________
                                                       Signature




STATE/COMMONWEALTH OF _______________________________

____________________________COUNTY, ss.


ON THIS  ___________DAY OF  ____________, 2016, 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.



                                        _______________________________
                                                NOTARY PUBLIC




                                        COMMISSION EXPIRES _________________
                                        QUALIFIED IN STATE/COMMONWEALTH_____________

                                        
                
                                        TURNED WITH APPLICATION on 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
                                              (if applicable)
























                                                                         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 ________________________.
                                                                                                                                                                                 _______________________________
                                                       Signature


STATE/COMMONWEALTH OF _______________________________
____________________________COUNTY, ss.


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.

                                        _______________________________
                                                NOTARY PUBLIC

                                        COMMISSION EXPIRES _________________
                                        QUALIFIED IN STATE/COMMONWEALTH_____________