Fillable Application-for-License-to-Collect-and-Transport-Refuse-PDF Application for License to Collect and Transport Refuse

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Application-for-License-to-Collect-and-Transport-Refuse-PDF Application for License to Collect and Transport Refuse

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U.S.A. forms for Town of Greenwich

BROWSE TOWN OF GREENWICH (CT) FORMS

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Town of Greenwich Signature required
Department of Public Works, Waste Disposal Division Type online, print & sign
Holly Hill Resource Recovery Facility, Holly Hill Rd., Greenwich, CT 06830
Phone 203-869-6910 - Fax 203-618-0653 Application no._________
PwWAHaulerLicense Issued 5/2003 1
Application for License to Collect and Transport Refuse
Answer all questions fully
To the Commissioner of Public Works:
Pursuant to the provisions of the Refuse Section of the Sanitary Code of the Town of Greenwich, the
undersigned herewith applies for a license to engage in the business of transporting refuse. If license is granted,
I agree to abide by all provisions of the said Sanitary Code, including starting hours.
1. Applicant Name_____________________________________________________ Soc. Sec. No.________________________
Last First MI
2. Birth date______________ Birthplace __________________________________________ Home Tel.__________________
3. Home Address_____________________________________________________________________________________________
Street City/Town State Zip Code
3a. Other home addresses in past 5 years________________________________________________________________________
___________________________________________________________________________________________________________
4. Name of Business_______________________________________________________ IRS Tax #________________________
5. Business Address __________________________________________________________________________________________
Street City/Town State Zip Code
6. Business Tel. ______________________________________________________________________________________________
7. Business is operated as a: Sole proprietorship Partnership Corporation
If business is operated as a partnership, list:
8a) Names, dates of birth, home and business addresses of all owners and partners, including limited and
general partners:
8b) Names, dates of birth, home and business addresses of all persons receiving or entitled to receive a percentage of
the partnership profits, and the actual percentage that each is entitled to receive:
If business is operated as a corporation, list:
9a) Names, dates of birth, home and business addresses, and percentage of ownership of all officers and directors:
Application for License to Collect and Transport Refuse (page 2)
9b) Title of each officer:
9c) Names, dates of birth, home and business addresses, and percentage of ownership of any person owning, holding
or controlling more than ten percent (10%) of the stock of such corporation other than the above officers and
directors:
10. If the answer to any portion of 8a, 8b, 9a, or 9c is a corporation, list the names and titles of each of the officers and
directors of such corporation, as well as their dates of birth, home and business addresses, and percentage of
ownership of such corporation. Also list any other person owning, holding or controlling ten percent (10%) or more
of the stock of such corporation:
11. If any of the persons listed in 8, 9, or 10 above hold such ownership in trust for or otherwise for the benefit of any
person, partnership, association, corporation or other like entity, list such person, the name of such other person or
entity for whom such ownership is being held, his home and business addresses, and percent of ownership being
so held:
12. Have you, a member of your firm, a director or officer of your corporation, a stockholder owning, possessing or
controlling ten percent (10%) or more of the stock of your corporation, any person listed in the answers to
questions 8 through 10 above, or any member of your family ever been arrested, whether convicted or not, for any
reason other than a minor traffic violation?
Yes No
If yes, state particulars: charge; court; date; disposition for each offense:
13. Sections of Town served:
14. Number of Accounts:
Commercial (list them):
Residential (list them):
Application for License to Collect and Transport Refuse (page 3)
PwWAHaulerLicense Issued 5/2003 3
INSURANCE
Truck Liability:
Named Insured _________________________________________________________________________________________________
Insurance Company_________________________________________Insurance Agent ____________________________________
Address_________________________________________________________________________ Tel. __________________________
Amount _____________________________ Policy No. ________________________________ Expiration Date_________________
Public Liability:
Named Insured _________________________________________________________________________________________________
Insurance Company_________________________________________Insurance Agent ____________________________________
Address_________________________________________________________________________ Tel. __________________________
Amount _____________________________ Policy No. ________________________________ Expiration Date_________________
Workman’s Comp.:
Named Insured _________________________________________________________________________________________________
Insurance Company_________________________________________Insurance Agent ____________________________________
Address_________________________________________________________________________ Tel. __________________________
Amount _____________________________ Policy No. ________________________________ Expiration Date_________________
MINIMUM LIMIT OF LIABILITY – GENERAL AND AUTOMOBILE
Bodily Injury: $100,000 each person Property Damage: $50,000 each occurrence
$300,000 each occurrence $50,000 aggregate
_______________________________________________________________________________________________________________
Permission is hereby granted to the Town of Greenwich to investigate fully any information needed by the Town
of Greenwich in order to process this application. A license will not be granted without a satisfactory clearance
from the Town of Greenwich.
Applicant Signature _____________________________________________________________________________________________
NOTICE
Any person making a false statement under oath, in addition to having his license declared void, is guilty of a
crime punishable by imprisonment of up to one year and a fine of up to $1,000.00.
State of Connecticut
SS: Greenwich ____________________________________ 20 ______
County of Fairfield
Subscribed and sworn to, before me on this _______________________ day of _____________________ 20 ______
___________________________________________
Notary Public
Authorization to Release Records
I, the undersigned, hereby authorize you to release to the Greenwich Police
Department any and all records that you may have concerning me, my reputation,
character, and general fitness; to include but not limited to criminal and motor vehicle
arrests, or any information of a confidential nature.
I hereby absolve and release you from any and all liability, damages, court or civil
action, by complying with my request.
Full Name __________________________________
Date of Birth ________________________________
Address____________________________________
Witness ______________________________
Date _________________________________
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Application-for-License-to-Collect-and-Transport-Refuse-PDF Application for License to Collect and Transport Refuse

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Completed 12 July 2020

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