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Home My WebLink Aboutmarine fueling permit 2026Department of Fire Services Commonwealth of Massachusetts Mobile Facility Application for Marine Fueling Permit (FP-293M) "Application is hereby made in accordance with the provisions ofChapter 148 ofthe General Lawsand 527 Code of Massachusetts Regulations, for a permit authorizing the "Use, Storage and Handling of Flammable and Combustible Liquids on Waters of the Commonwealth, including requirements for Marine Fueling Facilities, Mobile Marine Fuel Vehicles, Fuel Barges and Fuel Vessels". Application for Permit is hereby made in accordance with 527 Code of Massachusetts Regulations {CMR) for the calendar year )olu by NAME OF BUSINESS:I|tJ-T J,^c- Nome oJ Ftm, Corporotion, PeRon LOCATION OF BUSINESS ",r\u )l^r BUSINESS MAILING ADDRESS 2e.+ $r+ u Qo 4zax 1tl Street Numbet / P.O. Box Qru^n,r)rn"''^o-du(-? Aty/Town S oX br[T oasl BUSINESS EMAIL NAME OF OWNER IL ADDRESS OF OWNER RESPONSIBLE PARTY OPERATING IHIS BUSINESS FORMER OWNER IFTHIS IS A NEW BUSINESS FORMER MAILING ADDRESS: f.cot,t L So.*r^ tl Ab*r- NER TELEPHONE Sotr tcx ciol Street Number/ P.O. Bo, City/Town Zip code I have read andlmderstand the provisions of 527 Code of Massachusetts Regulations (CMRf related to marine fueling Yes (wJ No( ) ,/Operation is YEAR ROUND (r/) SEASONAT ( l, if seasona I include dates of operation operation is nw Vf RENEWAL ( ), if renewal please provide previous year's MtPermits Flammable/Combustible Liquid to be dispensed is: Class l( ) Class tt ( ) Class ttt ( ) * i. * I intend to fuel during the hours of darkness: lf yes, list hours that you intend to fuel during darkness I have night lighting 2o( Wt veslrf no1 1 Yes v{*ot I Mailcompleted applicetion to: Department of Fire Services . Attn: Licensing Desk Department of Fire Services . P.O. Box 1025, 1 State Road, Stow, MA 01775 978-567 -3375 . www.mass.gov/dfs FP'293M Rev.6/23 Revenue Code 0693 BUSINESS IELEPHONE I hereby attest that the following individuals have been designated Fueling Facility Operations 5upervisor(s) and are responsible employees who I have trained and consider to be competent in the handling of flammable and combustible liquids and are familiar with and understand the contents of 527 CMR 1.00 related to Marine Fueling, and the operation, mechanics and hazards inherent to the handling of flammable and combustible liquids and the fueling of vessels: Address Oote of Bifth Name Address Date ol Bitth Nome Address Date of Birth ( U/check here and attach a separate piece of paper labeled "M1" if additional space is required. * Mostlr FAcrLrrEs - TANK cARGo vEHrcLEs List eoch tonk corgo vehicle: Yeor MakeNehicle ldentificotion Number Registrotion Number Yeor MokeNehicle ldentificotion Number Reqistrotion Number Yeor MokeNehicle ldentificotion Numbet Registtotion Number listed. (VCheck here and attach a separate piece of paper labeled "M2" if additional space is required. (A separute opplicdtion, liting tee ond pemit is requircd for eoch seporute city, town or firc ditttict) FP-293M Rev. 6123 Revenue Code 0693 Nome You must include a photocopv of the motor vehicle registration certificate (RMV3) for each vehicle Mail completed applicatbn to: Department of Fire Services . Attn: Licensing DeskDepartment of Fire Services . p.O. Box 1025, 1 State Road, Stow, MA 01775 97 8-567 -3375 . www.mass.sov/dfs aoV\r,.l La^J,\4 6(A.nJ ( ) Check here and attach a separate piece of paper labeled "M3" if additional space is required. \A separate dpplkdtion,liling lee ond permit is requircd lot eoch sepordte city, town or firc distrid)l hereby certify under the penalties of perjury that (1) to the best of my knowledge and belief the above statements and attachments are true and accurate, (2) this application is made upon the express condition that any and all other applicable authorizations necessary have been secured and (3) I have filed all Massachusetts tax returns and paid all Massachusetts taxes required by law. (Authority: Chapter 62C, s. 49A, MGL as amended by Chapter 233, Acts of 1983). Print Name:FL^r,sl- T"ll-^s [at/rv Social Security or Federal Employee ldentification Number of the Business:0t zs-tsslD Signature of Applicant:lav^-- PI.EASE NOTE THAT ONTY APPLICATIONS WITH ORIGINAI WET SIGNATURES WII,I. 8E ACCEPTED. PHOTOCOPIES OF APPLICATIONS WII.L NOT BE PROCESSEO. FIRE DEPARTMENT NOTIFICATION AND APPROVAT I certify that I have inspected or caused to be inspected the above fueling facility (sites) and found them to be acceptable locations. I am directing that the following restrictions shall apply Signature:// ,/,.rfL^r Date:L-/ -2 L Heod of Fire Deportment (or Designee) 1+Z/"* Zn"orc Print name of Heod of Fire Deponment or Designee ond nome ol Fire Department PI€ASE NOTE THAT ONtY APPLICATIONS WITH ORIGINAI. WET SIGNATURES WILL BE ACCEPTEO. PHOTOCOPIES OF APPI.ICATIONS w[r- NoT BE PROCESSEO. Mail completed application to: Oepartment of Fire Services . Attn: Licensint Desk Department of Fire Services . P.O. Box 1025, 1 State Road, Stow, MA 01775 978-567-3375 . www.mass.qovldfs FP-293M Rev. 6/23 Revenue Code 0693 Approved product transfer (fueline) siteIsl: Date: ( ) Check here and attach a separate piece of paper labeled "M4" if additional space is required. A Guide to the Aoolication for a Marine Fuel Permit for a Mo bile Facilitv (527 CMR 1.00 and M.G.L. c. 148) Application for a Marine Fueling Permit for a Mobile Facility is made on Fire Prevention Form, FP-293M. This application may be obtained on the DFS website at www. mass.govldfs. The application may be photocopied, provided that allsignatures are originals. c All applicants must read the regulation. r One application per city, town, or fire district. o Fire Department Notification and Approval must be completed and signed by the head ofthe fire department or his/her designee within the jurisdiction of the fuel transfer. By this signature, the fire department is certifying that they have knowledge of the transfer of fuel, the site is in compliance with the regulation and any local restrictions are included in the terms and conditions of the permit. All permit applications must be signed by the fire department. o MOBILE FACILITIES - TANK CARGO VEHICLES must be completed by those applicants seeking to use a cargo tank vehicle to transfer fuel to a marine craft. ln addition, a copy of the Massachusetts Registry of Motor Vehicles registration certificate (Form RMV 3) must be attached. o You must submit a separate application for each city, town or fire district in which you wish to conduct refueling. For each city, town, or fire district, YOU must forward a completed application, the renewal notice (it applicable), all of the appropriate docu ments listed above, and a check or money order for $lfl).fl) made payable to the Commonwealth of Massachusetts, to the Division of Fire Safety, ATTN: Marine Fueling Permit, P.O. Box 1025, State Road, stow, MA 01775, on or before the expiration date (December 31 of the year issued). All incomplete applications for permits will be returned to the applicant. Any delay in the issuance of a license or permit, due to an incomplete filint, will be the sole responsibility of the applicant, and could result in civil and/or criminal penalties pursuant to 527 CMR 1.00. Mailcompleted application to: Department of Fire Services . Attn: Licensing Desk Department of Fire Services . P.O. Box 1025, 1 State Road, Stow, MA 01775 97 8-567 -337 5. www.mass.gov/dfs FP-293M Rev. 6/23 Revenue Code 0693 Secure, read and understand 527 Code of Massachusetts Regulations (cMR) related to Marine Fueling. This regulation is available from the State House Book store, Public Document Room 116, Boston, MA 02133 (Telephone 617-727-2834],, and an unofficiol copy on the DF5 website at www. mass.sov/dfs.. M1 Driver Fi6t Name Driver Last Nam€Address D.te of Birth IMM/oo/YYYY) Edward Justin Hurst Paul Donald Albert lourdan Mikel (evin Costa Hero Obert Tasha Vaillancourt Richardi Gendron Tekten Laroche t01211967 6/311966 4/28h964 3/1711973 sh8l196s tl2211961 al6/1997 s19/t99o s/1sh997 61s11962 259 Mei8gs Eackus Road Sandwich MA 02563 83 Nauti.alLanp South Yarmouth MA 02664 74 Mountain Hill Road Plymouth MA 02360 32 Point of Pines Road Centerville MA 02632 455 Governor Prence Eestham MA 02642 75 camp Steet Hyannis MA 02501 895 Sandwich Rd Bourne MA 02532 18Searsville Rd South Dennis MA 02660 4 DoaneSt Eastham MA 55 Captain Bellamy Rd Wellfleet MA 02667 M2 86 70 54 Unit #Year Make Licence Plate f PETERBILT W49330 PETERBILT J18493 PETERBILT J23478 MtTSUBtSHt K41575 PETERBILT 32198 lnternationa X15951 Peterbilt X30797 PTRB Y23803 Vin 2N P2HJ7X9N M771523 2N PLHD7XO7M734966 2 N PN LDgX22 M578149 JW6FFP1E73 MOOOO22 2 N PLHD7X85M849960 3HAEUTAN7PL71552O 2N PM HJ7X9PM829075 2N PM HJ7X3SM6935O4 2022 2001 2002 2003 2005 2023 2023 2025 59 63 89 91 95