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Check the appropriate box: Business Type(required): 1.14 I am a employer with l 1 employees(full and/ 5. ❑ Retail or p m -- ------- 6. ERestanrant/Bnr/Eatng FEsttab_lishment ----- _ 2.❑ I am a sole proprietor or partnership and have no 7• 0 Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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: 1-I RT 012 lA- C C l D E NT R-N D S N DE(vl Nr i 1 f C O 1" WP} N 4 Insurer's Address: ONE- TA.i < '.P(.(=tee 300 S 0011.1- STATE sr! '1 r� i,00ZCity/State/Zip: S yR A WS , 132-02, Policy#or Self-ins.Lic.# LU e G ZS5 5 oZ, Expiration Date: I (9- O 101 O 19 Attach a copy of the workers' compensation policydeclaration page(showingthe policynumber an 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 pain and pen ' of perjury that the information provided above is true and correct. Signature: Date: ///2 9// Phone#: `�j. 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