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TOWN OF OXFORDBoard of Health325 Main Street, Oxford, MA 01540Phone (508) 987-6045 ext. 4Fax (508) 987-3934boh@oxfordma.usAPPLICATION FOR SEPTIC SYSTEM INSTALLERS PERMITFEE: 150ALL SEPTIC SYSTEM INSTALLER PERMITS EXPIRE DECEMBER 31st OF EACH YEARTHE TOWN OF OXFORD LICENSES INDIVIUALS NOT COMPANIESInstallers Name:Company Name:Officer/Owner Name:Company Officer/Owner Signature:Address (Street, Town, State, Zip Code):Telephone: Fax:Mobile: E-mail:A copy of your current Massachusetts Hoisting Operators License is required to obtain a permitto construct on-site sewage disposal systems in Oxford, Massachusetts.NOTE: As the licensed Installer YOU are responsible for all aspects of construction.YOU are responsible for any persons you allow to perform work under your license.The Board of Health reserves the right to close the installation season at any timewithout notice due to freezing temperatures.
New Installers:1. The applicant must have a minimum of one year working experience working under a permittedinstaller from any town in Massachusetts.2. The applicant shall provide proof that a permitted installer, for a minimum of one year has dulyemployed them by submitting a copy of a W-2 form with no less than 1000 hours of workexperience.3. The applicant shall pass the Title 5 Installers exam given by the Town of Oxford Title 5 Inspector. Apassing grade of 70 is required. Contact the Board of Health office to speak with the Title 5Inspector.Installers who have worked in other Towns:Installers who hold a current Installers license in at least three (3) other Massachusetts towns will beallowed to apply for a permit provided the following:1. The licenses in the towns must be current.2. The licenses must be in the name of the Installer who is applying.3. A copy of a signed Certificate of Compliance in each of the Towns where the installer islicensed mustbe submitted. Those COC's must be signed by the Board of Health.List the three (3) Other Massachusetts Municipalities in which you are licensed to install subsurfacedisposal systems:TownLicense NumberDate License ExpiresPlease answer the following questions:1. Have you ever held a permit in Oxford in the past?Year2. Has your permit to install septic systems in any town ever been revoked?If yes, please explain the circumstances and indicate where it is revoked.
SEPTIC SYSTEM INSPECTION PROCEDURESPrior to any construction on the septic system, the installer must sign the construction permit and receivea copy of the stamped and signed approved plan.The following procedures are required for septic system inspections:1. Installation Permit:a. No inspections will be performed by the Board of Health office unless a permit to install hasbeen applied for at the appropriate Board of Health office. All fees and proof ofinsurance must be submitted at that time.2. Inspection Frequency: (to be performed by the design engineer & the Board of Health)a. Excavation Inspection (bottom)b. Component Inspection (tanks, d-box, pipe, stone, etc.)c. Final Gradingd. Stabilization (hay, mulch, environmental matting)e. Any need for re-inspection will require an additional fee.3. Requests for Inspection:a. All requests for inspection must go to the Town of Oxford Title 5 Inspector. YOU MUSTSUPPLY THE PERMIT NUMBER OF THE APPROVED PLAN TO THE TITLE 5 INSPECTOR.b. All inspection requests require a 48-hour notice. However, it is usually performed within 24hours. Plan ahead.c. As stated above inspections will be attempted to be performed within 24 hours.Inspections will not be performed on holidays when the Board of Health office isclosed. Again, we reserve the right to inspect within 48 hours.d. In the case of inclement weather, the following will apply:Inspections will not be performed until the rain/snow has stopped and the leachfield area has dried. For excavation inspections the installer shall re-scarify thebottom area and call for re-inspection. The installer should take care in workingaround the leach field area until the area has dried out and is stable/firm enoughto work on.e. Upon inspection you will be notified by the system inspector with the results of theinspection. It is important that you give up to date contact information to the systeminspector and the Board of Health.f. Any installer who proceeds with installation of the system at any stage without notice fromthe inspector or clerk (along with approval from the design engineer) risks re-installing thatportion of the project along with possible license revocation.4. Certificate of Compliance:a. The permitted installer is required to submit the Installer Certificate of Compliance (COC)to the Board of Health along with copies of the sand & stone slips used in the installation ofthe system.b. The company providing the sand fill is required to fill out installer as-built form and providea copy of the testing information that is not more than 2 months old. This information mustbe attached to the Installers Certificate of Compliance.c. The permitted installer is required to sign the Certificate of Compliance cover page alongwith the design engineer before the Board of Health engineer will sign.d. If an alternative system is being used the installer must supply a copy of the certificatestating that he/she is certified to perform the installation of said systems.e. If a pump system is being used, the model and model number of the pump along with acopy of the electrical permit is required with the COC.f. The installer is to sign the separate Certificate of Compliance page along with the designengineer and the Board of Health. Separate copies of the certificate (installer on one andengineer on another) will not be allowed.
The permitted installer is not allowed to make any changes to the system design without direction andapproval of the design engineer and the Board of Health Agent.By my signature below I am certifying that I have read, understand and agree to follow the aboveprocedures for installing septic systems in the Town of Oxford.Signature of InstallerDate
The Commonwealth of MassachusettsDepartment of Industrial AccidentsOffice of InvestigationsLafayette City Center2 Avenue de Lafayette, Boston, MA 02111-1750www.mass.gov/diaWorkers’ Compensation Insurance Affidavit: t InformationPlease Print LegiblyName ate/Zip: Phone #:Are you an employer? Check the appropriate box:4.I am a general contractor and I1.I am a employer withhave hired the sub-contractorsemployees (full and/or part-time).*listedon the attached sheet.2.I am a sole proprietor or partnerThesesub-contractors haveship and have no employeesemployeesand have workers’working for me in any capacity.‡comp.insurance.[No workers’ comp. insurance5.Weareacorporationand itsrequired.]officershaveexercisedtheir3.I am a homeowner doing all workrightofexemptionperMGLmyself. [No workers’ comp.c. 152, §1(4), and we have noinsurance required.] †employees. [No workers’comp. insurance required.]Type of project (required):6.New construction7.Remodeling8.Demolition9.Building addition10.Electrical repairs or additions11.Plumbing repairs or additions12.Roof repairs13.Other*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.† 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 haveemployees. 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 siteinformation.Insurance Company Name:Policy # or Self-ins. Lic. #: Expiration Date: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 afine 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 fineof up to 250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office ofInvestigations of the DIA for insurance coverage verification.I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.Signature:Date: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 (check one):1. Board of Health 2. Building Department 3. City/Town Clerk 4.Inspector 6. OtherElectrical Inspector 5.PlumbingContact Person: Phone #:
Information and InstructionsMassachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees.Pursuant to this statute, an employee is defined as “.every person in the service of another under any contract of hire,express or implied, oral or written.”An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or moreof the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or thereceiver or trustee of an individual, partnership, association or other legal entity, employing employees. However theowner of a dwelling house having not more than three apartments and who resides therein, or the occupant of thedwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling houseor on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.”MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance orrenewal of a license or permit to operate a business or to construct buildings in the commonwealth for anyapplicant who has not produced acceptable evidence of compliance with the insurance coverage required.”Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shallenter into any contract for the performance of public work until acceptable evidence of compliance with the insurancerequirements of this chapter have been presented to the contracting authority.”ApplicantsPlease fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, ifnecessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) ofinsurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than themembers or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does haveemployees, a policy is required. Be advised that this affidavit may be submitted to the Department of IndustrialAccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit shouldbe returned to the city or town that the application for the permit or license is being requested, not the Department ofIndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’compensation policy, please call the Department at the number listed below. Self-insured companies should enter theirself-insurance license number on the appropriate line.City or Town OfficialsPlease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottomof the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicantthat must submit multiple permit/license applications in any given year, need only submit one affidavit indicating currentpolicy information (if necessary) and under “Job Site Address” the applicant should write “all locations in (city ortown).” A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to theapplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out eachyear. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,please do not hesitate to give us a call.The Department’s address, telephone and fax number:The Commonwealth of MassachusettsDepartment of Industrial AccidentsOffice of InvestigationsLafayette City Center, 2 Avenue de LafayetteBoston, MA 02111-1750Revised 7-2019Tel. (617) 727-4900 or 1-877-MASSAFEFax (617) 727-7749www.mass.gov/dia
TOWN OF OXFORD Board of Health 325 Main Street, Oxford, MA 01540 Phone (508) 987-6045 ext. 4 Fax (508) 987-3934 boh@oxfordma.us . The Board of Health reserves the right to close the installation season at any time
