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The Commonwealth of Massachusetts
t.=�=ice
Department oflndustrialAccidents
_:e �,_ t Office of Investigations
s -- — , 1 Congress Street;Suite 100
'. =='= Boston,MA 02114-2017
. -r- www.mass.gov(dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organiation/Individual): O7Cee2 r5'/ewe L�7L` ,,
Address: 2/7 712002,1r7/7UT7 tie
{
City/State/Zip: C /7,7/5, T I'la 0,26,0/ Phone#: spa 77/ - a/fid
Are you an employer Check the appropriate box:
Type of project(required):
1.12 am a employer with ,2,5" 4. 0 I am a general contractor and I
employees(full and/or part-time), have hired the sub-contractors 6. ❑New ton
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity, employees and have workers'
[No workers' comp.insurance comp.insolence.t 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing an work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box II must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contacto s must submit a new affidavit indicating such
:Contractors that check this box must attached an additional shed showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
IIIIIIIIb _.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A,t 44. /Y11 7,nil 'CAS, 0•3
Policy#or Self-ins.Lie.#:VWC-/O J(nO/9 f}DC r- O/8/g Expiration Date: i///ao( ?
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 a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the WA for insurance coverage verification.
,
I do hereby eerafy I he •••••' s and penalties ofperjury that the information provided above is true and correct
Signature: _ Date: /1/4(0/a C/8-
Phone#: 8 •7 �_//Q
Official use only. Do not write ha 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/Town aerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
C ry Woitoiuoe lalackrackaa
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
\
t F.;t _. "
: .4 Type: Supplement Card
.. t.j;:i- -.-;'r-, Registration: 100121
OCEANSIDE,INC. �* - Expiration: 06/08/2020
217THORNTONDR i; ' }
HYANNIS,MA 02601 t_,._j .y `N_==j
ir_
\`z, �� ��l4* Update Address and Return Card.
•
SCA1 4 20M-05/17
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Supplement Card before the expiration date. If found return to:
Registration gxolration Mee of Consumer Affairs and Business Regulation
100121 - 06/08/2020 1000 Washington Street-Sults 710
OCEANSIDE,INC. ;: 7- Boston,MA 02118
•
aitol
D.SCOTT TON DR
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HY THORNNNIS,M O0 60 '' C, Not valid without signature
HYANNIS,MA 02801.r Undersecretary
•
•
•
d52.91....~~14 of offasodusets
.. ottoman, &Basins agsl.tloa'
License or registration valid for individual use only U. 'e ME IMPROVEMENT CONTRACTOR
before the expiration ti
P data If return to: �_ ';il
2t«�. TYPE
Office of Consumer Aftairsand Bamines! • EsP !D ' , aot�
10 Park Plaza-Suite 3170 Regulation OCEANSIDE.INC. •:;,•-,44.1:--: `
i Boston,MA 02116 `� ` `"
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meg_ ,.
D.SCOTT MIkiDOCI �,, „ r
t
217'Thornton Dr ".;-;:"4`` am, sera --
IHysnMe.MA 02001 , Undersecretary�Not valid� nun
tei ata t r
g
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Mat sachusefts
nt.,Public Safety
$t Board of Building Regulations and Standards
License:C114003gs
Construction Supervisor °� �"
.: .t QMMModt r
,
awu» y DENIMS w P
,
-7/ornmissioner O013000
frhExpiration:
Construction Supervisor .
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ii nresMtheinded
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loe eten of contain •
enclosed space. 99
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stabBURPainssdhnto p0sgseedasscausefoerevoation01018Deana- 1
i ops Uoindng Winnetle"vigil WbVen AOs.00VMPa
Client 586925 2OCEANSIDEIN
ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MNIDD,YYYT)
01/17/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:Ifthe certificate holder Is an ADDITIONAL INSURED,the poilcy(Ies)must be endorsed.N SUBROGATION IS WAIVED,subject to
the terms end conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER AR
• Dowling 8 O'Neil Insurance Agy !�;�Re,NN�s,IAT:506 775-1620 INC.NOP 5087781218
973 lyannough Road 4 ADRt.
P.O.Box 1990
Hyannis,MA 02601 INMMewaIAFFORDNGCCNIRAGE Niee
NAPE
R A,.,.r.r...a.,.. 17000
OMR$D MSUREN a,new N..otheNona Pe 41360
Oceanside,Inc.
217 Thornton Drive IauR!R c:
Hyannis,MA 02601 WAD`
INSURERS:
DRUMF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
19OCCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR 7YKQNa1MARCELSUOR*SR Val) POLICYNDIRER MMD /MM EXP UWE
A GENERALLMMMTY 8500066712 01/0112018 01/01/201• EACHOCCURIENCE $1,000,000
X COMMERCIAL GErERALMAaLIry Mi om"g.w1 $100,000
ICLAIMS-wee D occuR MED yank"ae;sum *5,000
FEMORAL S ADV INJURY s 1,000,000
cENERALAOGPEGATE 52,000,000
GENL AGGREGATE LIMIT APPLIESI� PER: PRODCTS-COMP/OP ADD s2,000,000
POLICY 1 1 JEGO'T 1 1 LOc $
B AUTOMOBILE LIAWRDY 102006166602 01/01/2018 01/011201• GFco ime�c,,,RSINGar<LMIT 11,000.000
ANY AUTO BODY INJURY(PW porno) $
—_ AAUUtE HS EDX ED way INJURY p(Ps $
X HIRED AUTOS X AUTOS1"4- NAED GPPr i°uAAOE
$
A X UMBRELLA X OCCUR 4600066716 01101/2019 01/01/2019 EACH OCCURRENCE s5,000,000
ECUS LIAR GLUE-MADE AGGREGATE SS.000.000
DEC. X RETENnon$10000
WORHFAS COMPEN$ATION /WC S AT . FTH.
ND EMPLOYERSUASLIW YIN I TORY
ANY
OFRCFH, HEMEMBFE RD(QUp ECUrIVE❑ NIA El.EACH ACCIDENT $
1(1N1.aA,ev I.,MNH) EL DISEASE-EA EA.LO EE 5
DESC(MPTON OFOPERATIONSbelow EL DISEASE•POLICY LINT $
9E5CRr•DN OP OPERATONS/LOCATIONS/VEHICLES(Mich ACORD 1N,AaaSaMl Rada sager,Y Mw..cow e,.eo e)
Job:Oceanslde/Offce
Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements.
Nothing contained In the certificate of Insurance shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION
Oceanside IncSHOULD
ANY OF THE ABOVE DESCREED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
217 Thornton Drive ACCORDANCE WITH THE POLICY PROVISIONS.
Hyannis,MA 02601
AUTHORIZEDREPRESENTATIVE
•
019115-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 colli The ACORD name end logo are registered marks of ACORD
#S204875/M204874 RPJZ1
•
CERTIFICATE OF LIABILITY INSURANCE DAT`(1NaDwYYY)
01/18/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms end conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not collet rights to the
certificate holder In lieu of such endorsemengs).
PROoUCERiuoxe4CT Linda Sulvan
DOWLING Si O'NEIL INSURANCE AGENCY 4'KMON`u4F.. (509)775-1620 WC.Net
Hyo__ IsullNen .Dom
973IYANN000HRD vsuro:R(0)ArfoeDlNoCOVERAGE rues -
HYANNIS _ MA 02801 nowt A I AIM MUTUAL INS CO 33758
INSURED INSURER a:
OCEANSIDE INC INSURER C:
INSURER D:
217 THORNTON DRIVE INSURER E:
HYANNIS MA 02801 wsurienF
COVERAGES CERTIFICATE NUMBER: 230844 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLJCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND COIUTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
Pia TYPE OF INSURANCE PGA
-1 POLICY EFF POUCY DIP LMS
LTR INTIK vivoUMM
YD POLICY NUMBER MNDIYYYYI MMDWYYWI
COMMERCW.OENERALCAIRRY EACH OCCURRENCE $
+BTU RENTED
WAG-MADE OCCUR PREMISES Mg oceunswel S
MED D (Ne ora wool 4
_ N/A PERSONALE ACV INJURY
RE
GAGGREGATE EGATE LARIES PER GENERAL AGGREGATE S
RPOLICY EI IRLOC PROCUC S•COVADP AGB S
OTHac
AUTOMOBILE LUBILRY ED IED SINGLE LIMIT S
mcdOsnli
ANY AUTO BODILY INURY(Pm person) 4
_ N/A BODILY INJURY(Pwmpddenu S
PROPERTY WAAGE
HIRED AUTOS NON-OWNED IPM seddenliS ,
4
UMBRELLA LIAO OCCUR EACH OCCUREI CE S
EXCESS IW CLANG-MADE WA AGGREGATE 4
DED I I RETENTIONS
WORKERSCOMPENSATION XI STA 16"-
AND EMPLOYER,LIASRTIY Y IN
ANYPROPRIETOA ICEOEr ULEraeERRpEXCLUSEm CIlI1VE [ WA NIA VWC10090198022018A 01/01/2018 01/01/2019 EL EACH ACCIDEM a 1,000,000
(NyeMw,sy In NG EL DISEASE-EAEMRDYEE S 1,000,000
DESCRIPTION OF OPERATIONS War EL DISEASE-POLICY LIMIT 5 1,000,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACM tel,AddNenY Remarks SeDRAde,ny M mRRRSC Imam wow Y required)
Workers'Compensation benefits Wil be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 OB B.no authorization Is given to pay
claims for benefits to employees In states other than Massa:husetb If the Insured hires,or has hired those employees outside of Massachusetts.
This certificate of Insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the
Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govawd/workerscompensalonAnvestigadonsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
Oceanside Inc ACCORDANCE WITH THE POUCY PROVISIONS.
217 Thornton Drive
AUTHORIZED REPRESENTATIVE
Hyannis I MA 02601 Deryaf CPCU,Vice President—Residual Market—WCRIBMA
01988-2014 ACORD CORPORATION. MI rights reserved.
ACORD 23(2014/01) The ACORD name and logo are registered marks of ACORD
•
. • of tuf TOWN OF YARMOUTH
• _•F '� ° HEALTH DEPARTMENT
3t;x c
1$
��'t• PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: /061 005"O e1
OS -1,45 re. -4 Z
Proposed Improvement: -CA,'4..,.11 Ca) -1- ?er4r Fb-e-L-1 rri
art 0(4r arca (caw n'#GUC9° cralid �lZ /
Applicant: tile/5A" .( o o nh/O-'/S Tel.No.: stir'n i'3//p
Address: 21? fh•wn-tan Drive 1-4 &tiN .' Date Filed: P'Z'lg
•'Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: Marl Mt1kit t Da-nnt3 Cony
Owner Address:2'15 Ma en S+. UJWrctr".rvt oafl( Owner Tel.No.: $O% 2-75'780
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e.,Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: Com! ball /,Kam DATE: 1-1-
// PLEASE NOTE
COMMENTS/CONDITIONS:
- .. MGL AND FIRE
• TOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
07 / ERRORS OR OMMISSIONS DO NOT RELIEVE
�/ THE APPLICANT FROM THE RESPONSIBILITY
ditgb OF"AS BUILT"COMPLIANCE.
'y¢ DATE:
INSPECTOR
YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: Arts Dance Studio Address: 1061 Rt. 28
Contact Name: Steven Jenney Phone: 508-737-4620
Y NO NA Subject Regulation
E
S _
X Access for Fire Apparatus 527 CMR 1; 18.2.4.1
X Building Numbers MGL Chapter 148;sec 59
X *Flammable gas/liquid storage 527 CMR 1;42.2.2.1
X Fire Lanes 527 CMR 1;22.3
X *Service Stations 527 CMR 1 ;16.2.3,16.2.3.1,30.3.2
X *Hazardous Materials Storage 527 CMR 1;60.1
X *Kitchen Exhaust Systems* 780 CMR,527 1;50.1
X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28
X Fire Alarm Systems/CO detection* 780 CMR,Chapter 148;,527 CMR 1; 13.7
X *LPG Storage Chapter 148;sec 9,10,28&527 CMR 1;69.1
X Use and Occupancy(FH Building Class) 780 CMR;302.1
X Sprinkler Systems* 780 CMR&Chapter 148 sec 26 A-I
X Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.234.1.1
X *Upholstery 527 CMR 1;20.6.2.5
X *Trash Containers 527 CMR 1; 19.1.1, 1.12
X Any Hazard to the Public Chapter 148;sec 28
X *Curtains,Draperies, Blinds 527 CMR I; 12.6.2
" YFD permit required-depending on occupancy and submittal
*Per 527 CMR 1 13.1.8, a permit is required from the Fire Department to shut down any
fire protection system.
Description of planned project/other requirements:
The YFD supports the applications, subject to applicable submissions, permits and
inspections.
Plan Reviewed By: Captain/Inspector.7Cevin.?Gini Date: 08-02-2018
Copy for Applicant fel Copy to Building Department I I Copy to Fire Prevention
Entered in Firehouse I-1 Final Inspection
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• 5 uefee44-el ',c 4- C.s% Jin a 12` A C S kf 1 `Z
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REVIEWED FOR BUILDING AND ZONING CODE COMPLI•
•zC ANCE ERRORS OR OIVAISSIONS DO NOT RELIEVE ThE
4APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT'
Z COMPLIANCE. .
Yarmouth Health Department
•
=� 1--ILDIN6 • PPR I,� ED
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--\--- - -- - -- FILE COPY