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HomeMy WebLinkAboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (60) / `� (o(� �ac� 6 �9,�2s��arN �v�S I, Date.......!..��2..l.'.......... 4 r10R7F� TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING CHUS�t� This certifies that ....., �� `1C�C P o has permission to perform .... ..F'.�!+-4 ..:........G.p .�. ..,�:............... wiring in the building of.....C� ^"�. t«.- .,,`.� , ..............:................ at ...1`D. ... .D..........✓.�' .......,-. North Andover, ass. Fee... .... --.........Lic.No.l .. ......................................�!................. ..................... . 1 'ELECTRICAL INSPECTOR' Check# i ` Cemmonwm&o`t'/lamac" Oil'icial Use Only Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS .1/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordancewith the Massachusetts Mechical Code(MEC),527 CMR 12.00 (PLEASE PRINTW INK OR E LL FO TIM Date: City or Town of: To the eaor of Wires: By this application the undersigned gives notice of his or her i on to perform the electrical work described below. Location(Street&Number) (j d Ow Owner or Tenant Telephone No.97eJ73-SiTr Owner'sAddress Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boa) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Plumber of Feeders and Ampactty Location and Nature of Proposed Electrical Work: 1�./ff 49 Completion o thefollow' table may be waived by the Lm Zector of Wires No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.Of ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above E] - ❑ NO.of Emergency Leigliting d. grud. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.Inieten an tiatiDevices No.of Ranges No.of Air Cond. Tom Tl No.of Alerting Devices No.of Waste Disposers Heat p I Number lTons 1KW No.o dntaiued Totals.I I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Conn ❑ � No.of Dryers Heating Appliances KW Security No.of Devices or Equivalent No.o afar KW o.o o.of Data Wig: Beaters S• Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications inng-. No.of Devices or Eanivalent OTHER: Attach additional detail ff desirec4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under thee'and penalties of perjury,that the information on thus application is true and complete FIRM NAME: LIC.NO.: Licensee: to /2 Signature LIC.N k� (Ifapplfcable,enter" P'fn the If baKlilte) t Bus.TeL No., • Address: 105, �cU•c u 41% Alt Tel.No: *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my si below,I hereby waive this requirement. I am the(check one owner El owner's a ent. Owner/Ag ` SignatureA&L A LJAAAM Telephone No1PERWTFEE.-_$ �j t r i 42211015 Division of Professional Licensure.Lice Search The tfficial Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ......................................................................................................................................................................................................................................................................... Locale a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name: GARY C. BERGERON REFERENCES& HOLLIS, NH RELATED INFO NEW SEARCH I Disclaimer Regarding This Licensee has additional Licenses,click here to view them." Website License Searches Glossary of License Status Codes Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN More... TYPE CLASS: E License Number: 21105 r Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 3/9/1995 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,April 22,2015 at 8:44:52 AM. O 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us h(tP:IAicense.reg.state.ma.uslpubtic/pubUcroseo.asp?board code=EL type plass_E&Iicense rxanber=000021105&color=redBlb=EL 1/1 Uq/•L'Z/LU10 Qu:zL F8K fz(J6r1407 THE_INSURAIICE_CO. 1 002/002 ACQDATE"W)9MYY) CERTIFICATE OF LIABILITY INSURANCE 4/22/15 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- IT the certiRcale holder is an ADDITIONAL INSURED,the polieyjles)must be endorsed. N SUBROGATION IS WANED,subject IG the bans and conditions of the policy,certain policies may regWrean endorsement. A statement on this cal 1111caft doss not canter rights to the certifkate holder in lieu of such endomemerd(s). PRoDum Allied Specialty Insutrance,Ine NCONTACT AM&: 1D451 Gulf Blvd Treasure Island, FL 33706 ftr IAA W 8002373355 DDR IN&URER AFFORDING COVERAG E NAIL s INWR9tA; T.H.E. Insurance CoMpany 12666 INSURED Larry Cushing Enterpriaes, LTD I ptO; dha Cushing Amusements INsuItERe: `� 196 Wildwood Street Wilmington MA 01887 INSURER D: W 6URER E: INSUREI!F: COVERAGES CERTIFICATE NUMBER, REVISION NUMBER: THIS 13 TO CERTIFY TMAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TtiE 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 ISSLIED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES t7 scmEO HEREIN IS SJBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SVGI POLICIES,LIMITS SHOWN MAY HAVE 13EEN RECUCEDBY PAID CLAIMS. IL LTA TYPEM INSURAE •ee[ as PQLICY NUMr3ER M M p NCLIIMT3 GENE3LALLIABILIrY EAC}•IOCCURRENCE S 11000,000 A COMMERGALOVIERALUAMITY CPP0101485-04 06/15/34 06/15/15 300,OOD PRWNSF9 Eim Fm S CLAIW64ADE OCLUR MED p(P (Mr one PVrw n) S PERSONAL SADV INJURY S 11000,000 GENERALAGGREGATE ; 5,000,000 GENT AGOACOATE U14T APPLES PER; PRDOUCTS•COMPIOP AGO t 1,0 0 O,O OO POLICY PRO LOC s wTOmoBILEL9ftg1u*Y S 750,000 A ANTAVTO CPP0101485-06 06/t°/14 06/IS/15 OODILYIN"Y(Pe,Person/ s ALLOWMEDX SCHEDULED AUTOS AUTOS BODILY INJURY(Per m=iden( I HIREDAUTC3 AoT< 1) PRDOERTTDAMADE q PUP= S UMWELLALIAROCCUR EACH OCCURRENCE S EXCESS LIAII HCLAIM34"OtAGGREGATE S MM RETENTION t S WORKERS COMPENSATION A V• aTFI ANDEMIPLOYM'L(A0IL1TV YIN ANY PROPRI EMWPARTTIERIEXECUTIVE EL EACH Arr C1ODJT S CFFIC "EMBER EXr.LUGED7 N f A lHowdalwy In NN) E.l.DISE/SE•EA EMPLOY S vyes,dewltw urder DE6CRIPTION OF OPERATIONS bsWw E.L.DISEASE-POLICY LWrr S OVAMIP7I0N OP OPBRAT-0045/LOCATION61 VEHICL6B(AAsch ACORD 101,Add Mond Rename Se1lsdWe,FRIM spec Is required) GENERAL LIABILITY COVERAGE INCLUDES THE OPERATIODTS/MAINTENANCE OF INSUREDS OPERATIONS INCLUDING ELECTRICAL MAINTENANCE/WORK - EMPLOYEE - GARY BERGERON, PROOF OF GENERAL LIABILITY, A;ERrFICATE HOLDER CANCELLATION PROOF OF GENERAL LIABILITY COVERAGE SHOULD ANY OF THE ABOVE OESCRIBEO POLICIES onCANCt'LLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WrTH THE POLICY PROVISIONS. A REPRES TATI i ®19118-gotCORD CORPORATION, AN rights reserved. ACORD 25(2010105) The ACORD name and logo are r"Isbred marks of ACORD �.d A%uq-4u.,cuAj ui:oo Am cz eire prevention System 5083033473 PAGE. 1/ 2 .^P visit our web site at https//www.most.gov/dpl/boards/EL 82 FIRE PREVENTIOU SYSTEAS INC GARY C BERGERON NO � 41 BRIGHAM ST UNIT 16 MARI.SORO Mil 01752-5143 t Toro,lba 00wh AhM AN Pwbrwoft ONMAN a. • !M f 'CS t .._ _ ..._ !CIA _-t1 '%# ISSUES E.•i0L1.0f♦ING 1rEMSs AS.:w D 14A _T r E•I,ECTR I C I AN'"�:� PREVENTJ(1 5YSTEMS INC �QT V* C� _ s is �i3 mw 017§2-51 _ 1523Z`.f-B-_. ••l�,1�i.�*�d b5' � Date...............h3................... Vj0R7'#f TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU ............ This certifies that .....C31V has permission to perform ........... &--W F. ....................I............................................. wiring in the building of..........Spp-,' Cart, ^\-PL- UA .......... ... ......................... .............. ........................... at . .....25� rth Andover,Mass. V................ ........ FA..............................Lic.No)S................... -- % /I cALINSPECPOR Check# Top e— UIIKI�0 A r ���h �, bei. w� �� ��,� �5 ��� ? � �� �v�:l�.��. �I t 5 ����S �5 c�e�,� .mac� �,�- �. �In . � c �� — Apr 01 13 07:56p RICKETY RANCH 603-883-6326 p.2 - OL—Ki 1 15.Unl;r l a'� <✓OtlU!'-:'t:l:JG:�:::.4����G!��".r.._..._ tI�IJ. ' ._ • � Y=iti11 - -rn r �r - n o-ie9= o _, erui er l Funa.es '+FE ` and F~Chet:gid Occupancy �--- Ni101�! R�GULAT IONS11 e...110'1} p_a„c 5laral V i 1 ` PRrmR ELEC L RIICA L WORK rave e r � 'ill 1: L e o 5?'r GTS?'CO p( �work to a.�..r€n�necl i3 at:ca d�a�ID�1rizssa:.hs:tts EVeevieal Cad..��'o� ��ii � 17PE�.LL IN OR11�4TJ'O;v) y}ete:i.n n CJ ��j,,�,4SEPR!�'�'lT'I1Tlti OP, odor orl�Yft•es. To the fuse.. � City or Tawn of: 1�� he, m By this toPlicazion the undersi.ned Pv_s Tla� of I!IT DT- t a u D`�_ '�'c elLe.TiGal`"off`'� :°0 bocatiaa(31eot Nntoper) I CD q d Telenhcne No. 0 nn -� Owner er Tenant Y 0/4"� J Owner's Address J Ca � � o ❑ (check_apraprialle!KT) �.J :� coon wilt 2 butldi�ap_rmi�": s flus permit in conjtAn y A.utuoF:zanou No. Purpose aS ❑aeg- d❑ ;�lo_ oNE_ters vers ov.rh�a❑ �SIS�eS.2VI�� Q`��' 1 1_�14.O��fCLrs volts ave:asad �nrd amber of Fi?ptitTs and AMc2city l Lo:2von and Nazzure Ai Proposed Eiecirical Wort. Carnnle6Dn of the toilowi ig table may be w ai.+ed'ov dx 7rjo^c�r of w ru• ho.of. '-�-rw �1°2a of Cell.gusp�-(PadElle)-aIIs .�.cu51vTu'7er ;rlo.of Re:..ssseL+rtsmiBaires y enerators No.ofSotiuos +ps;,,at lurnivait'e cutlers psf@ve Ia- 11do_at m_ro_acy c�arze No.of). ►t Wires 5wianmina F ool ted, ❑ _�ga. ❑ �aat>=tv Units i LSO.oo Oil$tt2�n_r5 Teo.of keceotacte t�-tiets n.ai �=tair�ht;� iTva. as Burmers knsinatin6 Devices !otzi te�o.D€A="Coud. Tows Ido.of 4lernro I3�ic.� N No.of Ranges .�,�E ertrer ors j'-L�'► a oe 5eli oacatnea �—. 1 J)etec�'oalR.Ie= =II i:es ��-- Ise_of Wzst=Isisp�se� 'I'or21s:! lrLssait�a! ❑ �t6°- 5nacd-AAra Heave ?W -�❑ EDIIIISCt10t1 F3o.of Tiisliw2sia_rs Se�s'iiY 1•Stems'� �ggeAtiag EPpEnace, rw Ido_of Devices or EnurpJeat No.of DrYe.-s t it o.of 1x10.0? Dat2 WC1Ilg: He2i:rs h-pd , gazss No.cf Devices or Ecilivale,t Ne.of Water Telecommtmicstions V1'iria�: �No.oCMotors Tot2l) ' No.o`IDevic"_s or xouivlat I > No.Hydromass2Cut S2tQr113Is i R: �- T ` r,ires. j 0 or ra re rrcd by irc nupeucr o, f' �narh aaei:ianJl dere:/if�esue� � eu rquiredby rzuaicinalpoucy.) Esfimated Value o'fElectriccdll Woti;. � ' InspecDons m be ttqutst-din ac �tc corda wi l g--C R t!C,and upon complerioa work to Start: IhT543t'i��dE:E CO-�'b G>% liulcss waived by thoowner;=aetntit for'tae periotivance of el~cm l work man israe u�l'sc N the lic_nse�prot'i9es RA of liability snsurance iaeluA'we"comal�d operstoe cove-,ue 0?is mbs�tial egalvaltnt rat on&ersiM=d cznti�ts th=such coverage is a fort~,and liu a:aioiied�mof of ram:to the pe mit iss'aina on D•t_M4_Nch- ❑ soup D Oryx ❑ ts?ec� Q carrify,under rhe mrd pexallics ofperiury,that the in orMI ion on thisMW N,.LkE: appiicauor.is True end campl�e ' 2 G-e/Z- LIC. NO.: ILicensee: 4/►tet Si gn2 tare } �C� aur �LM►.v 0.: T �- �' tcabls,enter men fir"in the%icerse � L7 lel.No.:P FLY V_ or'-ess: (� =P=M.G.L,c. 0,s_57-61.s_cur;.y w3nc r,_gt'sss Delp rmmt at PuOt�c Sar-.y"S iacsts ( I.ic.No. GYMER's DZSUR_'_NC.r,'Ar fI"vr,: I a-m aa27s that the Licsnsce does not have the liz6iliiy insv-ancc cavcrc::Dxmal'.y By M),sismz=a below,I usre�dwwaivye IbisTer_pL 1 stn th=(Ctlecl:ott_l 1 ov�^uer �own:t's a¢ent. rsquied by 13w. L 7 3 3.5$ Z.d LL5tr8998L66 �'r sy�� g7� 6ui a ` 4 89.90 S L L O AV r , I r r r ' 7 IV. IVidl ILII I rium. Ividridnne Uuud 3/LO/Lu IJ 4.uU.43 riw (raye L UI LJ CERTIFICATE OF LIABILITY INSURANCE °ATE(, ,Yrr(, 0 1226/2013 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 INSURERtSI, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and 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 died Specialty Insurance,Inc. CONTACT NAME: 10451 Gulf Boulevard PHONEFAX AIC No Extj: AJC No): Treasure Island,FL 33706-4814 A DRL 1-800-237-3355 INSURERS AFFORDING COVERAGE NAIC# INSURERA:T.H.E.Insurance Company 12866 INSURED Lar .C ,fii p rulter rises;L-TD INSURER B dba: Cushing Amusements INSURER C: 196 Wildwood Street INSURERn: Wilmington, MA 01887 INSURERE: INSURER F 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 THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR LTR TYPE OF INSURANCE I POLICY NUMBER POLIDD EFF MPOMUCY EXP LIMITS A G04ERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CPP0101485-02 0611512012 06/15/2013 EACH OCCURRENCE $1,000,000 PREMISE „„�, $ 100,000 CLAIMS-MADE ❑X OCCUR MED EXP(Any one n) $ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000 000 GEN'LAGGREGATE LIA4ITAPPLIES PER:POLICY M.M PRODUCTS-COMP/OPAGG $1,000,000 LOC AUTOMOBILE LIABILITY $ CE SINGLE IT Ea acztdeBINntl ANY AUTO NOUILY INJURY ALL OWNED SCHEDULED (Per Person} $ AUTOS NON-OWNED BODILY INJURY(Per actdden4 $ UTOS HIREDAU-OS AUTOS PRe�aEiRd DAMAGE $ A UMBRELLA LIAR X OCCUR $ X EXCESS LIA9 ELP0010338-02 06/1512012 06/15/2013 FACH OCCURRFNCF $1,000,000 CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTIONS A WORKERS COMPENSATION $ AND EMPLOYERS,UUIBILITY x WC Su TU 0TH ANY PROPRIETORIPARTNERJEXECUTIVE Y JN WC123893 05/2712012 05/27/2013 • - l� OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ I,OOy,yUQ (Mandatory In NH) "yes,descobetatder E.L.DISEASE-EA EMPLOYE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY OMIT $1,060.000 A Excess Liability ELP0011151-00 04/2112013 04/30/2014 $4,000,000 EACH OCCURRENCE $4,000,000 AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addtional Remarks Schedule,0 more apace Is required) EFFECTIVE FROM 4/21/13 THROUGH 4179113 ADDITIONAL INSURED:JOSEPH N.HERMANN YOUTH CENTRE,INC.:NORTH ANDOVER YOUTH SERVICES;OZZY PROPERTIES,INC. AS RESPECTS TO THE GENERAL LIABILITY PERTAINING TO THE OPERATIONS OF THE NAMED INSURED ONLY CERTIFICATE HOLDER CANCELLATION Joseph N.Hermann Youth Center,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 33 Johnson Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE,DELIV IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. Ozzy Properties,INC. 1600 Osgood Street AUTH D VRESE AmE North And ver,MA 01845 V ©1988-2010 ACORD -- PORATION. Ail rights reserved. ACORD 25(2010105) The ACORD name and,logo are registered marks of ACORD 4 < r?(Ptl tn 7 01�41 ly c o do I r- V _ _ 1 9L6680 £I/I£/LO 3 SOIIZ £065-6b0£0 HN SIiiOH iaa -i:ioi 1VN S0i m: Noa3sa3a � xaes �ML 3sNmn 3Aoev aRL S3nsst j 1MVI3l2I.1.33M NVYYA3Nbnor 03a V SV SNV131HJZ3-13 • n E.',.tie ..^.f(�`.a. S/ 3SnH3VSSVW:fO H.LIV3MNOWWOO r COMMONWEALTH OF MASSACHUSETTS mw ELECTRICIANS REGISTERED MASTER ELECTRICIAN OWES-WE ABOVE UCENSE To: ; GARY C BERGERON 105 NARTOFF RD HOLLIS NH 03049-5903 15232 A 07/31/13 889977 I i•am itmlt DetecIF No"m peftatom i - 07/17/2012 13:17 5089916292 PAGE 05/06 The Com tonwealrh o-ri assachttsarts • Department of lndus6ialAccidentv Q,QIce,ofInvesl gaWns 600 Washblgion Street Boston,NIA 02111 L01 www xwmgov/dia Workers' Compensation Insurance A ffidavie General Businesses A RPHeaut Information Please Print LeuiblY Business/OrganizationName:- i/ e/ �(�S _j Address:__1_g (o U dlWooGt.. s5` — City/State/Zip: U)i L M i W -O rJ Phone#: Are yon an employer?geek the appropriate boa: Business Type(required): 1.( I am a employer with employees(full and/ S. ❑Retail or part-time)Lo 6- Q Restau &ffiar/Eating Establishmimt 2.0 I am a sole proprietor or partners*and have no 7. ❑Office and/or Sales('mel_real estate,auto,etc.) employees worldng for me in any capacity. [No woftn' comp.insurance required] g- ❑Nov-profit .3.0 We are a corporation and its officers have exercised 9. ❑Entertainuueat their right of exemption per c.15'2,§1(4).and we have 10.0 Maanfaet ming no employees.[No hers'comp.iastsrance required]: 11-E]Heath Care 4.C] We are a non.profit organizat$M staffed by volunteers, ,n .�/ with no employees.(No workers'comp.kwranoe req./ 12,14 other /-s Yds as�l e 1 *Any a VGemtthat dhotis bac#i must also fill oat the sccfiw below showit;Ocir workers'cmnp msatiwt policy h6cmatiom "If the ec ep"Ie vel xs hove vxemptw thwhselvc%but the cor;mAva hes other employces,a wodebrs'compewWor policy is required and such an orgminden Should check box R. 14M an employer that is providmg workers'c�n imurance for(ny employees: Below is the policy iajormadion insurance Company Name: i�-YU sLM- A YU(-,e- Insurer's Address: L A0 C4 �V-A city/state/Zip_ ( /fie AS td Re, LAvUt , 3370 Policy#or Self-ins.Lie.#, ` 2 / _�l0 d Expiration per; 51d 7 h 0 i Attach a copy of the workers'compensaaftn pahey declaration page(sbowing the policy number and ><piration date). Failure to secure coverapc as requited under Section 25A of Mf3L c. 152 cart lead to the imposition of aim ival penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civ]U penalties in the form of a SLOP WORK ORDER and a fine of up to 5250.00 a day agd=the violator. Re advised that a cagy of this slat meat may be forwwded to ttte Office of Investigation of the DIA for insurance coverage verification. y do hereby Ven under the pens and enatiies oftedirry that the in or ruartkn provided above is true and cooed signature: I - Dtitt:�_ 1�1I a 0 Phone#. offs dal use only. Do not wrke in dbis araq to he completed by city or town of dffL City or Town: PelrmitUcense# Issnling Authority(chvie one): I.Board of He91th 2.Ruill ng Department 3.cityrrowa Clerk 4.LicensingBaard 5.Selet:tuten's Ot1'tce ti.Other Contact Person: Phone#' www.mamSov/din, Mam 24 2012 3:0*PM RLLIED 3PECIRLTY l"eURRNC 7273975695 _r*� an 144= !I7 EEWM LILY IMIMA 8 Mor �u��re PSODIIC�: �gvu�p 1 T.H.E. MU ra=o Comg&xV AIUM I17 Man=== Inc. 10451 car Boulamard 10451 Cum SWAevard Tree XS3.=d. SL 32709 TtGWUB r-IIS 33TV6 (owkiet Gofe: 40851) C,arsiet PnILW #: VM23993 Darria Fri= Pow hC M13606 . The lam; DM owl.Wit . . . NaUift : 195 W32dwwd Men �I.1ss3ugtot�. DSA 01887 ffeiu: 042714an Me W: 900CUUMM013 otbw vorYp3 aces not ob vim wMMS.. T". of Svs s: e*k"ra No =M VQWMAM Sa =A PODGY Rift ID.- 2. D:z. Fico-poS---7 " &Wcm 3,2201- a_:- ass S4&UZOIA to 12;G1- 8.ai.• aa —AZU12a1 at the it=r4d'e 8 ad Mfg. S. A. WoAon easct Z s: Part {ire of thm pDUW 4,pp2l" 3,a the Wot'jt WV Co�p�at�ea 7.� of !� ata Latad erg: S. BVIOPEN S3&et V lu==G: Patt T Q at the POLU r a U49 to .q3,& to an& mete I1stei = Iuo 3.A. Ma iiaits at ash 'SAA I&tV ends Pact fto are: Bodily Wury by Moss - o.fto...__ pe33J-7 limit Bt1dly W=r by pUmae I-opo-oa0 oadh umpl*M C. Otter States Znsttr8uee: All sumac onept: GA, im. Chi, tit,&, vw. and-WY D. M&LB Paiicg Lnft tbASM "doFrsommum and scb"ules; W000000VOT111) )=00308(04164) W000414(07190) WODOOMCCl/Ol) W000421Ct09/06) V=04=(09109) IM0601CW84) =806W06/95) WMMU4(05168) VOL (W99) W0100101(Ql108) IM0034I(04184} vW63GIt05186) vwoSo3l(D7/99) WC2o"051-06M ' td!~'2fl8fs0's`0661321 d. Tito praMIM for this PCIUg MM he doeormine& hp' o= WyAng .at Claea3f3catiaas, Raters sad Ram . AU AI-S', 3L belw 3s was3ect to verif3.eM%L= MAd rhaa by audit. Agedtlowume Cc" premium Basis Bata Par Estimated No. TwMa EfUnatad $100 or Amua3 A�ieal8ati6st - R�ss:ars4t3aaa Premdma Total a Peril $ 5.436.00 . P=Q�L�n � 9Qa,00 B Oaestaai � 338.00 TO 00 00 01 A UY JXe Department of Public Safety License to Operate Amusement Devices Marion V.Cushing License#: MA-011-12 (978)658-3928 Larry Cushing Enterprises,LTD Expiration Date: 6/15/2013 Cushing Amusements Certified Maintenance Mechanic 196 Wildwood Street Lawrence Cushing Wilmington MA 01887 UA I.D. # Device -U.S.I.D. # Device " U.S.I.D. #Device 07066 Truck Stop 10842_ High Lite Swing/Musical 10002 Go Gator 10853. Dicey Dragon 10003 Taxi Jet 13345: ` Ferris Wheel -- 10004 Round Up 13473 Casino 10005 Octopus 1002855 Wacky-Arch Bo ori r ce 10006 Sizzler 1002856.Firc Dog Belly Bouncer 10007 Merry Go Round 10009 Super Slide 10010 Rio Grande Train 10513 Gladiator Funhouse (Scooby Shack) 10567 Tempest 10602 Roll-0-Plane A 10802 Hampton Combo �J ✓// 12--p t2 Commissioner of Public Safety lSsued Date Page 1 of I