The URL can be used to link to this page

Home My WebLink AboutApplication and WC *****IN21Od AO 3UIS 2I3H1O 3131dWOD QNV 2I3AO Null 3SV33d*„x:” cul I OE E S = If1Q IMI1OIAIV s I$ :39NVHD 3LAIVN 011$ ODDVI1Ol 011$ 1213SS1Q N3Z021d— OSI$ 'kI"bs 000`SZ>_ SZ$ QOOd-DNIQ1\13A S8Z$ .1Ybs 000`SZ< 05$ '1J'bs OS> #.LIW2I3d 333 63211110321 3SN3DI 1 #.LII'1213d 13d CM-2111103N 3SNHD1I #.LI1N2IHd 33.4 Q I I1f1d321 HSN1011 :3DIA2I3S1IV132I 08$ N3HDJ.I}I 'QIS32I— _ 08$ 31VS3'IOHM 09$ "DIA NF\J O1 OD 00Z$ SIV3S 001< 0£$ 1Id021d-NON S£$ "IV.LN3N1.LN03 SZI$ SJ.V3S 001-0 #.LIIN213d 33d 4:132111103213S1\13311 #.L11A1213d 33d Q3211f1d321 3S1\13311 #.LIW213d 33:1 03211110321 381\13311 :3DIAII3s QOOd 'ua011$ 'IOOd12uIHMT 501$ }I21Vd 213"[IV21.L 55$ 3DQ01 `r 11 -e 011$1OOd DNIIAIIAIIMS_- 55$ dWVD 55$ NN1 ,S'O— 011$ -mow t SS$ NI£IVJ SS$ EMU "#I :Ad 33d Q3uI11O321 3SN 13F I #.L11AI213d 33d Q321If1d321 3SN3311 #111A1213(1 33.4 C13211f10321 3SN3DI'I :9NI943o7 VINO 1Sfl aaI o 4o--YLSL-91"ds 0-0ZBL-9)ds 000 # 'IV.LOI :NIIVHS INVVIf1V.LSHx 0o--b18t=91--x •98 .f7 •£ .Z .I •ssauisnq Io aaugd anoif lu aiij u um uiuut pun saidoa Mau apIAold Isms[ no/ •spaoaaa ,sanaA Isud asn lou mit Iuaul3andaa wail alit •uuoj sigl of suotluogil_1ao aa/foiduia Jo satdoo gouliu puu moiaq saznpaoozd unioiio-Iluu ut pautual saaAoiduza.znoic lsti asuaid •sauzll Hu In saslutaad alp uo Jannauew iloipuiali alp in paulual 301oiduz0 alio lsuai lu anuli lsnuz aaow JO slugs glum sluauzgsiiqulsa 39IAJOS pooj Hy :SNOI.LVDI,IIi2IHO H3I'IINIiH N/"" ' P 0 1 •I tvevno �y uiuluInut pile saidoa AAau spino td Isnut noA •sp.Ioaa.I ,s.Iua�f Isud asn Jou HHp%p 117/6112P1--r2J 'ogddu sup oi.uogeopuaao to satdoo gaullu 3S-Md •(u)(£)(J)600.065 2IJAL) SOI `slug 4 y' _ o, pop X.ImureS alums alp u!paupap su `uouuogilaao uaRaaily suit own aaicoidwa gulp-ii ` Alt sluaunistiqulsa aotn.zas pooj Iiy :SNOI.LV3IALL2IDD NEIa2I1TIV •Z •I •uo1<mado jo smog Oupnp alts uo (aid) a2augj ui uosaad auo lsuai lu °Aug lsnuz luaulgsTHqulsa pooj goua :TJ2IVHD NI NOS2IHd Z •I •IuauIgsiiqulsa anoif lu apJ n utuluiuut pun satdoa mau apinoad Isnui non •spaoaaa ,s. uaX Isnd asn Jou hint IuatulaudaQ twat'aq,L •uotluotiddu sap of uoImogia.laojo satdoo goullu asuald •000.065 2IIAIa SOI `sluauagsilqulsg ao!nzaS pond aoJ °pop 1ZultuuS aluls agl lit paugap su `Jaauuuyt uotlaaload pool u su pagilrao st oTim aaiioiduma swill-iinj auo Ism In anug of paunba.l aau sluaunistiqulsa aopuas pooj Hy :SNOI.LVaIAIIIIHJ - SIIHOVNVY\I NOI.La1.LO2Id.Q00,4 1. ‘or p t•A q D 17 vi sAA- IA a-' 4c 4 5' A 1,t-D •£ 1\ a i 1 t W c31,o - 1 •Z -7-9i-bold .4 i-As t NZl n a •1 •ssauisnq jo aanid Inca lu am u upu uiuul Rue sa!doa matt apinoad Isn't' noA •spaoaaa ,sanaif 3sud asn Jou'um IualulIudaq glivaH au •u1.zoj sap of suotluogrpao alagl Jo satdoo game puu moiaq saa/foiduza agl Ts!' asuaid •sauuil Hu lu sastuzaid uo aaicoiduza pa!juiao alio 2u!Auq `(}Ida)uotlultosnsaJ iciuuouzindolpau- �.tunuzuzoa puu piy lsaid pIupuuis lit pagilaao Jciluauno saaIioidlua oml Jo wnmiuiuz u lsii lsnul saolu.Iado food •Z 79ktd tk5 (n 1)ci •I •uaaoJ sup of uotluogilaao am jo Xdoo u uoullu pm (s)ioluaad0 food paluu2Isap alp lsti asuaid -ACEI gluts iCq paarnbaa su'.toluaadO hood u su pagilaaa aq Isnlu aosinaadns food aq1, :SNOIIVaIdLL}I1f 'IOOd L - -0 91.A.11 Of / bti• " i • o :SSMIQQVDINII'IIVIAI "Eos -b.1'-G I e :vim, X91,E)d H 5(AJ nd_ :MANN S,21LDVNVY\I VI Lop LS :(d"IHVJTIddy AI) IAIVN NOIIVHIOd2IO3 ,bd 1151 A liu J:HIAIVN 2IH O ( iJJ) 'bra oui U dd./L 5-A aq u n L c ) 0901 :ssa2ivay'IIVv\I-[ a vs- :SSMIQQV DNl'IIVF aoii5-.5-i, L-904:#••II.LEt,9a© .0W `/'0wabA•N4(97-94nOf Es-s-:ssJQQyNOI.LVaO'I :QI xvi Oa 40'49 5,A 4)4..un H :HIAIVN IN1vAIHSIIHVISH ..1-caa.h1J:11V3H la sed uolluoliddu.1noA Jo umlaa alp lit linsaa {pm os op of arnju •L IOZ SI a, 'wag Q q slug, o I• aussaaau hili gamy pm uuoJ alaiduaoo asuaid 6102 8 0 AVW ori„ {, 1 ':. or `,I 1sN1aI'I 110,1 MOI.LVJPIddV ,e, ,ii,;,,,,, °i..„5 1m d,' j .r t „ .VOg H.LIlOIAIIIVA AO NMOL ,. c LI/ZI/I na)J /> 79.k-fid ke 1 : I.LI.L 28 HV VN INRId :HIIIIIVNDIS �j I ( 9,0 c© :giva N Zd E LIS V amnbmi AVL\I SNOIIVAONg2I '.LNRIAIHDNHIAIIAI00 01 2IO11Id H1'IVIH 3O Q2IVOg IHJJ AS QdA02IddV(INV O.I. Qg.L2IOdg[i dg ISIlIAI `('O1 g `1NHIAIdIllOg MNN `DNII.NIVd "3'i) "IOOd NO "I*IOIAI `1NdIAIHSI'ffl 1ST 0003 ANV OZ SMOI.LVAONg2I TIV •L I OZ `S i 2IggY\I1O 1G AS (S)ggi Qg2III1Og2I (INV (S)NOII.VOI'IddV'IVMiNg2I c1 11 I'Idb\IOO TH1. minim'01.AI 'IIgISNOdS12I 190A SI,II i£iaqutaoau o� I AIMMU f utoal Agenuuu um!suuuod:3DII ON •pa;igigoad st ivautgsilgilsa aointas pool.zo Hula!u ionpoid pooj Amp Aeldsip JO`uoREJ1daid Tutx000 zoopin0 9NfI00311000 LI10 •tiquoiIto pr1og atn wag pnorddh aoud On141snut`(Ooinaas ssaa2 umpouem uum 2upEOs aoomno`•a•i)sOJUO 3pis}n0 :SalVD �QIS,LIlO 'Tau uaaq anal sutt02 anoqe alp Imn uuttOd possaU uazoad inoA10 UO! Oona.' JO uotsuadsns Ng ui lingo.' II!M os op 01 aimed quautudoa 4H °H atli mumps sunsai aldun s rhino`.13isealatil Alquuout pue 2uivado o1 zoud qui paijnioo owls u Aq palsal aq i.snuz sitassap tzazotd :simasS3Q N1Z02IA •suUod aigipuoiunnoQ luautaaudaQ 42IeOH iapun sn•etu•glnowJ1 kmmm apsgam s,uMo1 atg wag Jo luautaredaQ paurelgo ag ueo suuol asatlZ quana paaaluo o42 aoiad ssmogsmogZL utaol uogeoilddV aoin.taS poo3 /Ctuaoduta,L paunbat o41 2utlg Aq luauntudaQ !memH ggnout_zeA age X3ilou ism! tgnouUUt?A 10 umo j 01l0 unium slaw otJM auoAuy :AarlOd ONRIHI,VO •2utuado o}aoiad siit?p (E) oang uogoadsui 010.oinpagos Juounludou atl�3ouluoo as13Old tuivado o;aoiad iuowii do otg po oadsui oq 3snut s1uatugsgquis0 aotnaas pooj JIV :9NIN3df 1DIAlaS 1100d 'IVNOSV3S LMIAl 1S QOOA •2uisolo Io skup(L)uanas unium pazanoo to pauu ip oq lsnuz pod 21iutuums punoa2 ui Joop3no/Clang :OMISO'ID 'IOOd •Jogeoioqi. jjioi rnnb puu Tuivado o3 aoud sicup (£) aa.q ivauii rndoU queoH alp powwgns pug `qui pagi too owls Aq lunoo oluid prepuels pug uuojgoo"elm`st?uoutopnasd Joj polsoi aq lsnuz Joium atlZ :ONIIS�1.2Ia1VM'IOOd •pauado pui poioadsui uooq suq pod atl3 lipun yam pod otg ui his oI pamoll1 ION oat? oidoad :nom ESV I'Id tuivado 01 aoud situp (£)aaag3 uowadsui aqI ainpagas 3uoluvedoQ 043 3o13uoO •2uivado 01 aoud 3.uaut1t?doU ummeaH a4 Aq popadsui aq isntu uosuos.ogl aoj pasolo uooq anal tlott4M sioodingm pug 2utpLM`2uiutuatms IiV:ONINMdO'IOOd S'IOOd •luoIsuwal po opisuoo aq Agenuo2 gulls `papuoun su `Oi,9 2I1AIO 0£8 ao Dt9 •o '"T10'IAI ut pougop `osioxg AouednooO utoo21 Jo uoiloalloo 041 01300Igns Si lug].Ifouidnoo0 •3uaisuwa3 patapisuoo oq lou Ilius uun 2ugiomp • JO Oouapisa!u su uun isan2 u Jo Osn •poiaad glum!(9)xis/fur unium scup(06)A3ouiu uml3 WOW 1011 JO 03a0J ue puii`sAup(0£)4441 uitll aaout Sou Jo Xouudn000 snonuguoo 01 IOJOJ Aguiouo0 Ilius Aouiidn000 3uatsuew1•ara4MasJO aouapisoi 10 amid Iidtouud u uni ureut Amp lug a iii3suou op o3 ojqu act pue anal lsnut s3ut?dnoo6 3uaisuiay •asn IO3og pup plow gum poimoossu XjIJ utolsno pug Aliaiiuipio qouudn000 pue/Cmoduza3 atl3 o3 pautug aq II�tIs 1iouudn000 luaisu j,`asn plot{JO Ialovuo suot3i1ituil aguuo sasodand.Tod :ADMVd9DDO ZN1ISNVILL S1MII/IHSI'IIV1.S1 WNI913012I3H,LO (NV ST11OIAI ON SHA QIVd 3I A'I11VRIdO2IddV )IOgHO ESV11d •s3iuuad ana 10 aouunssl JO IIiMOUOJ o3 aoud pred oq 3snuz suatl puu saxul glnouulA 10 umoI slc Q1HOVIIV (INV QgNDIS I.IAVQId3V 'dI\IOO S�2J 1N'IOM ?IO QgHOV11V dONV2IIISNI 3O '12I fl 110 `Q3N9IS (INV Q313'IdIJI0D 3g ISIlIAI IIAVQI33V 3ONVM I1SNI NOI.IVSN3dI,IO3 SJIMRIOM aI.VI.S Q3HDVI.,IV 3111 •aouUansui uoi3lisuadumo3 s,Jolio j 10 O3uotlipoD ii anal Sou soop Aut?dutoo JO uosiad ii 1i ssauisnq u O3wodo 03 3iuuad JO.Osuaogl ifuM JO TMOuaa JO aounnsst plotl o3 pounboa mou st tl1noutreA10 umoI 043'9 uogoasgn5 `OSZ uogo0S`ZS I Jo3dmID Jopull NOI1NIIISINII'JQV ,, The Commonwealth of Massachusetts Department of Industrial Accidents is '1111111 of LI in". i Office of Investigations 5. "1-It3.li a1 Congress Street, Suite I00 - 11 Boston, MA 02114-2017 ?,,,,_ �N ,.. LFT www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please �Print Legibly Business/Organization Name: N U C1+€v S G ✓'-2 e C /� 0-1--(3,./Q Address: 5 53 R 0 0 ) -a ic) City/State/Zip: (A9 f s.)- 1 Q f ly OJ ! Al. . o2 hone#: 6 p g - 7 75 - 5 ti 09 an employer? Check the appropriate box: Business Type(required): Areyoam a employer with_' / $ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. E Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, a.OS p 1 a I t 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 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'compensation insurance for my employees. Below is the policy information. Insurance Company Name:8torKS l,7)re 1-JC1 VI4 firma 1 6(J wDl. Insurer's Address: PO B e,x A. - City/State/Zip: CAJ j f k eA _B rnre l PA ^10 76'3 Policy#or Self-ins. Lic. # 5 N W C C 6 I 861 Expiration Date: 051o/202 8 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 certi unde the pains ndpenalties of perjury that the information provided above is true and correct. Signature: CA Date: 5!a 6 / , I Phone#: 021.7— ' I q e 0.3 c Official 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/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia