Loading...
HomeMy WebLinkAboutApplication and WC _ � pa�,�e� rrrrrWNO$30 3QIS 21'.�1HZ0 3L3'Id11[OJ QNtl 2I3A0[1i1[1.L 3Stl3'Id+sxr• $ _ �RQ.LNIf10L�iV SI$ �3�NtlHJ3NIVN s6$ o��vaoy ors ixassaa n�azoxa— osS u�bs 000`sz> SZ$ Q003-'JNI�N3A SZZ$ '�'hs 000`SZ< OS$ ' #.LIY�RI3d �Hd 43211Ra�iI3SN3�I'7 #.LIYV2I3d 333 Q32IIf1d9TIHSPIH�1'i #.LIWZI3d 3H3 QH2IIfl��I�SN��I1 08$ �IHH�,LI}I'Q[S'3ZI— �'3�IAN3S'IItl.L3N OS$ H"NS310HM a / 09$ '�IANOINNIO� ( 09[$ S.Ltl3S00K 0£$ .LId02[d-NON S£$ 'IV.LN3NI,LNO�— h�a 58$ S,Ltl3S OOI-0� #,LITN2i9d 333 Q�2IIIla�1 HS�IH�['7 #.L1NRIfld 3Hd d�llflafl2l HSPiH�I'I #.LIY�'2I3d 33d Q�NIf1U3iI�SIdflJ['i ---— _... - � -- - . . . ----_. .__. _. . —___- — -- :�3idA:�S(lUud — - 'Ea08$ ']OOd'RIIHM SOl$ 71�IVd2I�17V2I.L SS$ �'JQO'I '�a08$ 'IOOd�JI�iILQL�IIMS SS$ dNN� SS$ PUdI SS$ 1fl.LOW SS$ NIHF'� SS$ H"�8H #.LIY�Ifld 9�d Q�IIf1U�flSN��I'I #.LIIN2I9d H�d Q3NIf1a32IflSN3�I'I #.LINi213d 3�3 Q32IIC1a3213SNff�i'1 ��A[I�Q07 ��uo �sn ��i,�3o a��s�� ,�� a #�so.i. ��rui�as iN�n�is� ,� •� ,� - �£ .,.�����1 ^ �z r�+ �i U •ssauisnq;o aae�d ano,f;e a�g e a►eauie� pue sa�doa n+aa ap�noad;smm �o� •spao�aa �s.�sa,f�sed asn;oa�i►n+;ua�ay�adaQ q;�eag aqy �uuo3 siy�o�suoi�zoi3i�zao aa�foidma3o satdoo q��7e pue moiaq sampa�o�d�utxoq�-i�uz ut pautEs�saa,foidtua.�no�f;sTj aseaid •sauzt;I� �s sastuzaid a�uo.�annauzy� t�otjunag a� u? pauis.r� aa�ioiduza auo �seaj �� an�u ;snui azouz io s�sas SZ �� sluaLucistiqe�sa aoin.tas poo3 IIF� �SNOI.Ld�I3I.L2I�� H�I'IY�II�H _ ___._�_..�._----�,o�OA^3d�/ �Z (b!/ 'T �/� •uotleiado 3o smou�ui.mp alTs uo (�Id) a�.req� ui uoszad auo�seaj �e aneq;sncu�uaun�stiqezsa poo3 qoeg ��J2IF�H�NI NOS2I�d ��` 'Z ('�l 'I •;uawysi�qBasa.�no,f;e a�3 e a�e;u�em pas sa�doa n+aQ ap�no.�d;sna► no� •spaoaaa �saga,f ased asn;on I�in+;uam�aedaQ q;�eag aqy •uoi��oiiddz stu�o�uot���3tuao3o satdo�qoe��aseaTd '000'Ob5 2IY�I� SOI `sluaun�stiq�sg aotnzas poo3�o� apo� �nres a�e�s aq�ui paugap s� `iaSeu�y�uoc�oa�oid poo3 a s� pag�ua� si oum aa�fotduza auzil-IIn3 auo �s�ai �e an�q ol pazmbaz a.re s�uatuqstiq��sa aotn.ias poo3 ii�' �SNOI.LF��I3I.L2I�� - S2I�rJF>'N�Y�I NOI.L��.L02Id Q003 'b '£ 'Z 'I •ssaa�snq;o a�sid rno,f;e a�g s u�e;mem pue sa►do� ,tiau apinoad ;sna� no� •spaoaaa �sasaB ;sed asn ;ou ���,►� �uaaU.cedaQ y;�eag aq,j, •uuo3 sicg o� suot}eogtua� aa,foiduza 3o satdoo uoe;;e puz moiaq saa,fojduza asa�lsci aseald '�2Id�) uoc��iosnsag dreuouzjndoip.re� �Tununuo� pcze pty�szT3 p.repue�s `�a3es za�zm otseq ui pagtuao�ii�uaun�saa,ioiduza on�3o mnuztutuz z�sti�snuz s.�o�eiado jood -- ----- – •. '� � •uuo; sn;�o�uocieogivao aq�30,idoo�qo�e pue (s)zolazadp jood pa�eu�tsap aq;�stl as�aid •me�a;s;s,fq pa.�mbaa se'io;e.�adp�ood u sc pagra.�aa aq;sniu aos�naadns�ood aq J, �SNOI.Ld�I3I.L2I�� 'IOOJ , �SS�2IQQF�1Jrii'IIF�Y�I 9 - -s39 �#"I�.L ��Y�IF�'N S�2I�rJF�NHY�I ���'IgF��I'Iddb 3I) �Y�I6'N NOI.Ld2IOd2I0� / ��L�IdN 2I�NtY10 �SS�2IQQd rJnII'IIF�'Y�I �� - O �#"I�.L ''' �SS�2IQQF�NOI.LF��O'I L ����- �QIXF�.L Ja�i SSb,cy-� a��'� ��L�N.LN�IHSI'I�d.LS� a '1d30 H1lH���� uot��oTidde mo,f 3o um�az aq�uT�jnsai Ijin� os op o�amire3 , `5,�,.� qru aaQ,Cq s�uaumoop,f.ressaoau Ire q�eue pue uuo3 a�aidcuoo aseald * . � Zt�� f ,� � � s„r £i0Z- ,LINt2I�d/�SN��I'I 2I03 riOI.LV�I'IddV �� � ��JG1�fJz?��i� A,L'IV�I�O Q2I�0g H,LIIOLIRI�A�O NIMOZ � • � __ , SV1�C'✓)2-'-I � ����� ..--- � � ZI/60i01 'na� `�'�,y Sti-���•a�ii.t �a��N i�a ��� :�ni�N�Is �� � —��i�a � 'Id .LIS F>' ���2I�IF�Y�I SNOI.L`dAON�2I '.LN�Y�I��N�Y�IY�IO� O.L 2IORId H.L'I`d�H 30 Q2IH0g�H.;.�ig Q3AO�IddF�QNF�O.L Q�.L2IOd�2I�g.LSf1Y�I `�'�.L� `.LN3Y�Idif1�� �Y1�N `rJI�II.LNIF�d `'a'?) 'IOOd 2I0 'I�.LOY�I `.LN�Y�IHSI'IgF>'.LS� Q003 AN� O.L SNOI.L6'AON�I 'I'IF� 'ZTOZ `SI 2I�gY�I���Q�Ig �S)3�3 Q�2iIf1��2i QNF� �S)NOI.L`d�I'IddF�'IdM�N�2I Q�.L�'IdY�iO� �H.L N2IfLL�2I O.L�I.LI'IIgISAiOdS�2IIIO�I SI.LI 'I£iaquza�aQ o; i�n�f uT�i3�Il�nuue uru s�tuuad ���IJ.OAi •pa;�q�qord st;uauzqstTqe�sa aotnzas poo3 zo iie;az��fq��npo.�d poo;,iu�3o,Csidsip.�o`uot�Esedazd`�uni000 ioop�np ��u�oo�xooQino 'u�l�aH3o pseog a[{1 tuoz3 jenoidd�zoud ansq isnuz`(a�was ssax��en��ia�i�m q;im�ui��as zoop�no`•a•c)sa�eo apis�np �5�3�'� �QIS.LIlO •;auz uaaq an�u suua�anoqE a�IT�un�iuuad�assaQ uazoi3 mo�f 3o uotlzoonai.�o uoisuadsns au�ui �insa.� ijin� os op o� aanjre3 •�uaur�sedaQ�IeaH a� o� pa�tuzqns s�insaz aidures y�tn�`iag�a.�a��fit�uout pu��uivado o�.�oud q�i pagtua�a��s e�fq pa�sa;aq;snuz suassap uazoi3 �S,L�I�SS�Q Ai�Z02I3 •suuo3 alqep�ojunnoQ `�uauA.redaQ�leag.zapun sn•euz•u�nourre �n�mm�e a�isqam s�umoZ aq;uzo.�3 zo`�uauzuedaQ�IsaH a�le paute�qo aq ue� suuo3 asaqZ •;uana paza;e� a� o� .�otzd smoq ZL uuo3 uot�eoTidd� a�in.tas poo3 drezoduiaZ pa.zmbaz aig �uT13 ,iq �uauzuedaQ y�j�ag �nouue� aq� �i�ou �snu[ t�nouuz� 3o umoZ a� uT�im s.�a�Bo oum auo,fuy �1i�I'IOd�AtRI�.L�� •�utuado o;.�oizd s,fep (�) aa.ng uoi�oadsui a�ajnpaqos o��uau�redaQ�IeaH a�����uoo aseaid •�a►aado o�.�oud�uau�redaQ q�IzaH aq�,iq pa�oadsut aq�snuz s�uaunlsTiq�;sa a�tn.cas poo3 IIF� ��Atll�I�dO ��IA�I�S Q003 'I�'AiOSF��S ��IA2I�S QOU3 •�utsoTo 3o s�f�p(�)uanas uiy�inn paianoo.�o paure.ip aq;snuz Iood�uiunutms puno.B ui soop�no,C.iang :��ISO'Ia'IOOd •.�agEaia� ,fizauenb pu� `�uruado o� zotsd s�fep (£) aa.n� �uauzu�daQ u�IeaH aq� o� pauiiuqns PTT� `0.�I Pagtuao a��S s ,iQ �unoo a�ejd prepue�s pue uuo3?Io�I�lo�`s�uouzopnasd zo3 pa�sa�aq�snm ia;�n�a� :��[I.LS�.L 2I�,LVA1'IOOd •pauado pue pa�oadsut uaaq ssq iood a�jrlun�are Iood aq�ut�is o�pamojiE ZpN a.ie ajdoad ��.LON�SF�3'Id'�ucuado o�zoud s,isp(£)aaTy�uor�oadsui a�ainpauos o�;uauzuedaQ q�jsaH ac��o�uo� •�utuado o;zoud�uauzutidaQ��ag a�,iq pa�oadsu�aq�snuz uoseas a�zo3 pasoto uaaq an�q qon�m sioodTziqm pu�3utpEm`3uicuuz�s i�:��IAI�dO'IOOd S'IOOd •�uaisuezZ paiapisuoo aq�fiiezaua� Ireus `papuame se `�ti9 2IL�I� 0£8 zo��9 •o •Z•rJ•y�ut paugap se `asToxg �fouedn�op moog;o uot��aiioo a� o��oafqns st ��q� �iouedno�p •�uaisuez; pa.zapisuo� aq�ou ilzus �nm �utiian�p zo aouapTsaz s ss�tun�san��3o asn •poT.zad q�uouz(9)xis,Sue ut�Tn�s,Ssp(06)�aunz ueq�azouz�ou;o a�e�a.��z ue pu�`s�fEp(p£),flzng ueqi aiouz�ou3o�fouedno�o snonui�uo�o;za3ai�iji�.�aua�jreqs.i�uedn000�uatscre.�Z•azaun�asia a�uapisai 3o ao�id �dtouud E ui�;uteuz ,faq; lEt� a�e.�suoutap o; aiqe aq pue anzq 3snuz s;uedn000 ;uatsuezZ •asn ia;oq pue ja;ouz y�tm pa�eTooss�,Citaeuzo�sno pu�,iit.reutp.�o`�Couedn�oo uua;uoqs ptre,S.�zoduza;a�o�pa�iuzti aq jj�qs��u�dn000�uatsue.�Z`asn ia;oH zo ja�oy�3o suot���tuzil aq�3o sasod.md io3 ��I�AiVdII�aO.LAi�ISAiV�I.L S,LAi�L�iHSI'IgF�.LS��AiI�QO'I 2I�H,LO QAi�S'I�,LOY�t ON S3�I �QIF�d 3I�I'I�.Ld'RId02IddF� ?I��Ha �SF/�'Id 's;iuuad mo,i 3o aocrensst.�o jEmauaz o�zotzd pted aq�snuz suaij pue saaet qlnowse�;o un�oZ Q3H�F�.L.LF� QN� Q3NrJIS .LIA�QI33d 'dY�tO� S.2I�?I2IOt1c1 XO Q�H�F/.L.Ld ��NF�If1S�II 30 '.L2I�� 2I0 `Q�N�IS QAiV Q�.L�ZdL1i0a �g .LSIINi.LIA�'QI33V ��u�nsui uois.�su�a�o� s�iI�}IiIOM �.L�'.LS Q�H��.L.LF' �H,L 'a�ue.�nsui uot�ssuadmo� s�zaxzom�o�a�Eoi3iva� E an�u ;ou saop �icreduzoo �o uosiad e�i ssauisnq e a�giado o� �Tuuad zo asuaoij ,tue;o lEmaua.z io aouenssc pioq o�pazmbai n�ou st�nouu��3o unnoy aq�`9 uot;�asqns `�sZ uot�oaS`ZS I ia�dBq�zapun ; AiOI.L�2I.LSIAIII�1iQ�' � , . .. � The Commonwealth ofMassachusetts Department of Industrial Accidents Offtce oflnvestigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name: `7f1� �/ l(2 Gt,t IL�YSS �✓j" Address:�� ���vi(L ,�c�r�( City/State/Zip: v-� �• 6Z66 Phone#: � �—��{�f—;5Z`C� � Are you aa employer?Check the appropriate box: Business Type(required): . 1.❑ I am a employer with employees(full and/ 5. Re il - - or part=fune}:� 6. RestauranbBaz/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• ❑Non-profit 3.❑ We aze 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]* 11.❑ Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *My applicant that checks box#l must also fill ou[Ihe section below showing their workers'compensation policy information. xxlf the coryo[a[e officers have exempted[hemselves,but the corporation has o[her employees,a workers'compensation policy is required and such an organization should check box Nl. I am an emp[oyer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of t6e workers' compensaHon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposirion of criminal penalties of a Fme up to$1,SOO.DO and/or one-yeaz imprisonment,as wellas eivil petmmlEies in the form of a STOP WOl�-Og�Fg an�a_t"ine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigarions ofthe DIA forinsurance coverage verification. I do hereby ce�h;fy,u r the pai and Ities of perjury that the information provided above is true and correct. Si ature: <�a Date: 7� � L Phone#: (� Oj,ficial use only. Do nat write in this area,to be completed by city or town ojficiaL CiTy or Town: _ yQQj110lri td Permit/License# �- Is (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office Other Contact Person: Phone#: STj f3-3�19-�,�-3 j 2(�Z`f'� www.mass.gov/dia