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T114s�: #i�i�n�� c;za� ��� «t�t�ia�ed at tl�e Healili I�tp<�rin��ttt,��i•1ic�n�ti�c'�c>s���'s ti�ehsiie at�v�.�c��.�'a�tnt?tith,nl�cz�tz��cic�f lealih i)�.part�ni��[, I?o��nloac�iable�orms_ � EI2C)ZE,C�i T71�::�:ik;kT'.�'i: �'r<>zen c�zsserts musi�e testccl b��a�St<ttc certiti�ci[<�1���•ior t��c>�x ninw�<in+�mc�nt�tly therc<�att+:r.ti��iti���rnp(e r�,��lzs submitted to the E[�a(th [>e�jartmc;zlt. t�ailur-e t��ic�sca��=i11 rest�lt tn The�us{Sis�sic>n cjr 3•�vc>c:ati«n c�f y°cn�t-Fr<,r�n I)c�s�crt Perniic untit tt�e<i�sc��•e tem�::(za�e been znei. E)lt't`4IllE C,�,FES: t)titsirle cafes{i.e.,c>ut€3v«r se�tin���ith��aicer�uai�r��s�r�ic�},n���si ha�.c pric�r��s��rc��<�i E'rurr�tl��t3ttarci tfi']:(�aiill. t�IJTi?Llt)Ft+��Jf�(s:1 NG: C��tsi�c�i�cc�c��.ir��,�r��<i��•ai�c�n,�r Eii��it��-c�t a��;��fc�orl prc>duct�y a r�t�il ur fa�d s�rvice establisha�euz i�pr�rhi�+it�cf. lti+CITICE:Perat�itv run e�nnuail�Tr��n Jas�i��r;. I tc�T3ecerr�l�er�]. 1'C i��r'(7�t''�RESI'i}�T�iIBILI'i"�'Tt�RETLT�'v €�3:II;[�(}�rSF'(.F>`['��[�1'��;I�;I�'�':�I:r�I'I'1.�(;.=1Z'IUN(�l�1�D F�Ef)L.`II�I:€3 I F:t's(S`9 E�,�'1)k:>(.I:tU1I:31:.fi' 3�>?(i17. <�I.:t.. E��?i�f)�'t1"i`IC)�;S "€'C) r�^+�l' 1-'()t�3�� EST�BLI'sH?t���T. �L1C�T�L (3R P()#:�I,. {i,e_z P.'�6?��"t f'�',{T� tiE:bl' �QL'IPAILP.'T,EI�C;.).'�t?S�'�il:PI�:�'C)K['I�:I) Ct>.=�?vC),�E'I'Itt}VI_;F)I3�`T[�I;I3(`3<'�Ft[.)(3I'E tL;�1[.:1}I I'E:iC)F: "1'()C't)?vfl��};�C,�::�-1I:N7'. R�I�7fJV,'1'I"I()N4���1Y`K�C�L7#[21�:��[`l'k?;I'T.r�N. T)A"[�:; r � ..f g•i 7 �It:�'��t'i'C�Tt�: �='��. . ��t��t��t1a:�����.`r��t`�,�: i°�1�c R A rY� � �w rv�c 2 F°c:•,t()f1ZjE i { The Commonwealth of Massachusetts ������°�� Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 .���` Boston, MA 02114-2017 '�s � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�ibly Business/Organization Name: Tf�� f7 u�vE c M oTo R .11�N Address: � ��', S£,a ts� �c,j .A �E. So u i H �/'�1fZ/�►oUT�-� M A . C�� G G cf. City/State/Zip: So uT k �/ F+� n�►��r�i °.2GG 4� Phone#: 5"�f3 - 3 9 � 3 n b 2 Are you an empioyer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with � employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2•❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estate,auto,etc.) employees working far me in any capacity. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation poliey information. **if the corporate officers have exempted themse(ves,but the corporation has other employees,a warkers'compensation policy is required and such an organization shou(d clieck box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: C I�r U!j g Insurer's Address: �• n�r3o h I 4 S� City/State/Zip: �'1%'�1`�L��c� 2� /1'�� • 0 2 3 �� - t[.F t'v Policy#or Self-ins. Lic.# E �'G2 U3 �- 2 C- 2 q o c�.Z _G-�� Expiration Date: n 7' a G� 20 !� 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correc� -�l . Si�nature: �� ' •��^--�-- Date• �" ` �� - ° �' Phone#: >�$ � 3 R 8 - 3� 6 2 Offzcial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tmwn Cl�rk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia , . ��. `�� . �� : ��JTI�� u 'F I��TI�E. � � T� � `�� � �� o�� w �r 4, ���_s�'J��� �,. �1�ff i...d�������c.jF�a,_� .�� `�w f ! �U v �M S'�� �`�e Co�ma�wealt� �f �assachu��tts �EP�.T1V��1��� �� INDUS��IAL ACCI�E�T� " � �:€�rt��ess St�-eet, Sc�ate 100, Bostong l�assaehus�tt� 0211� — ?f��7 C�7-727--��OQ — http.//w�rw.��atenma.us/dia ,_;.�,� ;;-�c� ���- I��#.r�ssaci��s�;tts Gcn�,ral Lav��, Chapter 1.52. SeGtions 21., 22 cS'z 3£), lnis w�ti ���-c v��� n�ltt�e :t�<�: � E� 3�;;� prr,.��€ci�� f'��r aa�,�nent tJ c�ur injur�;ci empl�yees under the abave merti«�ed c�a�tF;,r?,t, � � �rsurin�wrih: GHUB� �__. _. N�'��IE QF INSURANCE G€�MPANY P .O. BOX i450 , PhIDG�L.EBORO N!A 02344-1450 — ___._.�__. ���x�.ss oF��sLTu�N��eo���r a:�Li.��-:���SQ�+�-�-i 7} g7-06-�7 T� G7-�6-5� �Y_ f� E� �;l���r�F� �F��C:`�'��rl�F�:`�'��;�: , . �� ;r,'��� .:h!� � .��- f�lE T L I h!S AGC 973 T YANNOEIG[-i R(� � � — HYQNhiIS �A Q2��� _.�....�_. i -„� T•t-��'��: ��I��LIR�1?��E_�.GEIs�T .A�DRESS __ _ _ _ _ Pk�E���,�_ ��° ---- rE�tv',' �'ISE �JPEf�ATIE�[�[S. L'G 1't0 SEAVTEW AVENEJ� - C:��� "'€-tc GUNES i�iOTfaR I[�t�{ SOUTH YtaRMOL1TH ' MA Q2664 _: _______ ^7�7� c ..., . ..'.F; F.'-._`�r f.r.FS � i i.YI L��S�S • ` - ;�;�`�, :":�����"� ��Ca�2.�ER.S COMFENSATION(�FFICER (IF ANY) �_�'T�: . _-- _ ��D��� ��.�.�..���E�� - ` �:;c: �f, ,vL: narn��ci insurer is r�quired in cases c�f pecsonal injuries arising aut of an� i;� the ec�urse :3f �����«��ne.n� ec� turnish adequa�e and reas��nable hc�s�itai and medical se-r-vices i� aecc�.rdance wit� ��-�`��; �,-z�t�.Ec�,�s f_>; fl�ae �Vorkers' Compensafion Ac�.. A co�y of the First Repc�rt c�f Injc�r�� must l�e �ive.�i t« t.h� ��,;=�rc�,cf �;mplc�ye�. The empl�yee may seleet his c�r her �wn physician. The reasonable cost c�f the ser��ee.:� =t��:ct�=c; �rv the tre�ating �ht�sician �vill be �aid hy the in�urer, if. the treatment is nec�ssa���� and reasc}n�lA;=, ::,_-F� ��;;z:a�� to tl,�- ���ork related injur��- In cases rcc�u.iring hospital �;ttention, emptQyees are heref�y nc�tt��.��i ._�__ ;? «E t�,ti.� snsurr;r ��s�srrangec�fr,r such attentic�n at tt��. . �e;�,?��C�.OF H{7�PITr�L ADDRESS � �(} B� P�S�ED �� E�P���R