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'a�ue.msui uot��suaduio�s�zaxao��o a����i�za��an�u�ou saop�ueduzo�ao uoszad��i ssautsnq�a��.zado o��tuuad.zo asua�ii�iue �o�n�auaa zo a�u�nssi pjou o�pazmba�nnou si�nouz.z���o unnos au�`g uot��asqnS `�SZ uoi��aS `ZS i za�d�u��apun � ' l�IOI.L�2IZSIl�iII�(I�' s.., � I .� : ' The Commonwealth of Massachusetts '. � Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 ' Boston,MA 02I14-2017 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses ' Apulicant Information Please Print Le�iblv Business/Organization Name: I' 0.�s R ive ��a_'���`oKf" �e.coH�4�eS Address: 3 6 ` ' ; City/State/Zip: � Phone#: .��� 7�7 �z;S��� ` C Are you an employer? C eck the appropriate boz: Business T�pe(required): 1.�I am a em loyer with �Li employees(full and/ 5. ❑ Retail art-ti �.* 6. j� 1�esia.urantBar/Eating Establishment ' 2.❑ I a sole proprietor or partnership and have no I 7. ❑ Office and/or Sales(incl. real estate,auto,etc.) � employees working for me in any capacity. ? [No workers' comp. insurance required] 8. on-profit ; 3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment ; their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing i no employees. [No workers' comp. insurance required]* � 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, i with no employees. [No workers' comp. insurance req.] 1 Z.❑ Other � *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'com ensatdon insurance for my employees. Below is the policy information. � Insurance Company Name:��/1� �_.� ,��,� Insurer's Address: S� ' , �1x� City/State/Zip: ' � ' Policy#or Self-ins.Lic. # /� " `�tYD `���Q /�'�---'�o xpiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy numbe a d e iration date). Pailure to secure coverage as required under"Section 25A ofMGi;c:I52 can Iead to the impositiori of criminal penaliies of a fine 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 fine of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of ; Investigations of the DIA for insurance coverage verification. � I do hereby certi ,u er the pains and penalties ofperjury that the information provided above is true and correct. c � Si ature: r ' Date: ( Phone#: ��� `— �� � � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: y�4{Z.Mo�T� Permit/License# suing Authon ' cle one): .Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Contact Person: Phone#: 5D8-39B-2231 x izy I wwwmass.gov/dia i f , �...�.+►.. ����� �� ' �� ': _ ��E��"t.�.�i�1����' tNFORMATlON`P�lGE` ` � A.#.M. Mutuat trtsurance Campany ,--�, 54 Third Avenue,Buriir�c�n,Massa�ti�e�is fli803-0970 (&i0j 876-2'T65 Npq t+�26t56 POUCY NO. AVV�C-400-70Z910'L-2013A PRt�!�. NEW RE�A 1. The Insure� Bass River Wa�erFrot�t Tov�ouses DBA: Ma�'mg addr�ess: i i 1 Norih Ma�t S`treet FEif�'*-"� Sanit Yarm�Ut,AAN d2664 Legai Entity Type: Otl�er Otfi6r t�i�n�shawn�owe: See Loc�tioca 2 The palicy period is from t�ttl�f�f3 `fo 061Ei1�i7� '#2A1 a.m.s�r�daN�ne at the�s m�ng sd�. 3. A. workers co�ec�sation�ns�,r�nce:Part one of ttre poNcy a��uie work�s cornpensar�on taw of ine � states�sted here: MA B. Err�y+ers'1.iab�y ir�surance:Paft Two af#ie pc�cy�p6es�w�orlc in eac:h s�s�ed in i�m 3A The rrnits a#�under PaR Two are: Boc�Y Icyur�t bY A�oadent $ 10d,000 eadt acddeiti �Y�►�TY bY� S 500,�p�y� ��Y���Y�Y� � i00,000 eacf�e�tiploy�e � C. Other States Insuranoe: D. This Po{'x�+indudes these Endo�nent�and Sc;ttedules: SEE SCHEDULE 4. -f't�p�for u,is�j►vr�be cis+�m�ea bg►our M�d�,a�oru,Ra1es ana R�g P�S. ' 1�k inforrrration r+sqtared belotiv is s�ed�a wer�fic�t6w��d�ge t�y s�x�t. C�ifications Prerrnturt 8�is -Ra�es - Cale � Per:F1a1 �ed Na T� � � lt+ifRA 0119.515 tNTER Ci.ASS CODE Mnimum Premium $274 To�a!�Mnt�f Premi�n �503 GOV C�3V �� STATE CLASS _INA �15 - MA Assessment Chg. $10 -lh�s poHcy,indu�g aN endorsemerns,is he�eby c�ot�ntetsigned by �������t.,,'�.'�_ 06Jb4f20#3 Au�orl�ed slgr�re oMe � -'�'' Servic:e Oific�: � Jsmes E Su�lvan 1[�surance 54 ThiM Av�ue ` Burlirtgton MIA Of 843 Te�ry,MA 01876 ` � � WC 00 00 Oi A(7-11j �as capyr[�ed m�af the Na�or�st C.o�on Coiape��sa6an� �ed x�h�p�on.