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HomeMy WebLinkAbout2016 CONSTABLE BOND Bond No.: S-829692 KNOW ALL MEN BY THESE PRESENTS, That we. Konald Bertheim of 16 Lenox Avenue Methuen MA 01844 as Principal and NGM Insurance Company of 4601 Touchton Rd East Ste 3400 Jacksonville, FL 32245-6000 as Surety are held bound unto the Town of North Andover in the full and just sum of Five Thousand and 00/100 Dollars ($5,000.00 ) to the payment of which sum well and truly to be made we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. Whereas, the above bounded Principal has been Appointed as Constable for Town of North Andover NOW, THEREFORE, if the said Principal shall faithfully perform all duties of his said office in the service of all Civil Processes which may be committed to him during the term of which he has been Elected or Appointed, then this obligation shall be null and void; otherwise to remain in full force and effect. this bond shall be effective on 9/9/2014 and expire on 9/9/2017 SIGNED, sealed and dated August 20. 2014 Ronald Bertheim Principal Ic By: Rona d Bertheim NGM Insurance Company Surety BY: J e E. Ouellette Attorney-in-Fact 68-MA-0038-08 6AM16 certificdo ertiftcate of Completton # a0VE; SETT Conflict of Interest Law bag completeb the Conflict of IntereM tabu . .� /- online training program on , _ 4 Rs J i}` 5/24/2016 Print Certificat " I Certificate Page 1 of 1 � 1 caste of complett'an State t Cam Sion Conflict of Interest Law Qltttilp Caron Summer Fun North Andover Youth & Recreation Services Town of North Andover bag tompleteb the Conflict of 3ntPreot Kai :�'�� S`��-G online training programs an 5/20/2016 Close Cerbficate Window http://www.muniprog.eth.state.ma.us/page554968.html 5/20/2016 Certificate Page 1 of 1 2016 JuH —t PM 2: Certificate of �Completio�t�}= '01 K R ssaa ':Comm s;on H SETTS Conflict of Interest Law Tapror Crane summer fun Youth and recreation services Town of North Andover bay completeb the Conflict of 3ntertOt RaW L f online training program on JJ l 5/20/2016 http://www.muniprog.eth.state.ma.us/page554968.html 5/20/2016 12/6/2016 Certificate Certificate of Completion state s Cm lion Conflict of Interest Law Darn Ca.q;!5ibp Event Coordinator/Bartender S bat completeb the Conflict of 3Jnteregt Ratn online training program on 12/6/2016 ids mac'` Print Certificate http://www.muniprog.eth.state.ma.us/page554968.htmI �/� Certificate Page 1 of 1 Certificate of Completion State g coy+ Won Conflict of Interest Law ASSISTANT TOWN ACCOUNTANT NORTH ANDOVER bao rompleteb Me Conflict of Intereot MaW ����� s��{� online training program onw 8/26/2016 Close Certificate'" -40 Niiol 9z :it Wn 9z 5nmoz htt„•i/.sn=nx miinir�rntt Atin ctatP ma iio/rarrASrA04Q html R/7ti/1) 1 A 9/11/2016 Certificate Certificate of Commptetton Sta0 s Com Sion Conflict of Interest Law [jag completeb the (Conflict of Interest law �5�4 t4l-\ online training program on y. FRI 9/11/2016 �n Y N ^i*7 O �"�I (�o�r� o n �� � bv.� .-� S vJ e9.c` '.�►- J�S m e\, 0 C, http://www.mLs iprog.eth.state.ma.us/page554968.htmi 1/1 Certificate http://www.muniprog.eth.state.ma.us/page554968.htmI 2016 4 P11 4: 0! Certificate of Completion State E ocs Commission Conflict of Interest Law �Oabita 39Iork Reference Librarian Stevens Memorial Library Town of North Andover bao completeb the (Conflict of Ntereot Ratio online training program on 1 12/11/2016 Print Close tificate Window Certfficate 1 of 1 12/11/2016 4:49 PM 8/18/2016 Certificate AMNL Aft- Certificate of COMPtettou Stair ics com ssion Conflict of Interest Law bay completeb the Conflict of 3nterta Rabe online training program on 7 8/18/2016 P O_ Oti lO >:r-CD !Tt t7>ZZN Mr http:/Mww.muniprog.eth.state.ma.us/page554968.htmi 1/1 6/21/2016 Certificate � E IW_,� ,. •, 9 kr •y. . is '7�� INk- • Ce ' ' eComykdon? ate State thics Comm+s�.or, l.-...onflid of i rQK 9 t ZZ ` cr% rrt rn has compCeted t& Conflict of interest Law -4v, q' online trains ro ram on 6/21/2016 f r r #, Print ' , Certificate http://www,muniprog.eth.state.ma.us/page554968.htmi 1/1 6/24/2016 Certificate Certificate of Completton State E cs Commission Conflict of Interest Law TOWN C�Ui ��� RWBuc bad completeb the Conflict of Interesst Rabe ��''`~ online training program on 6/24/2016 Print ` Certificate N o S2�> +:. cD M -r 01 C ^" ON Ci htfn-/AAAAwI mi ininrm ofh efnfc m lnn—r rAQrA hfm1 N 6/13/2016 Certificate 20 AN 14 P�+1 9: 2 Certif irate o i OWN 011-- sna c NORTH �=, zovE# Co letion MAISA SETTS Conflict o terest Law -Do&MGD -f3i&-41u16jf;P- s has completed the Conflict of .\=, Interest Law online training program on 6/13/2016 Print Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.htmi 1/1 Certificate 9/1/16 10:33 AM AOL care o Corn Cenon errs i p State lcs Commission Conflict of Interest Law michelle Dokimasck s Behavioral Technician Franklin School North Andover Public Schools 5�r! has compCeted the ConfCict of Interest Law onCine training p716 ram on Se tember r � 5 Print �i�'Certificate Window `ic Cert to C t card �014 e,GI OC :OI WV Z I d3S 410Z http://www.muniprog.eth.state.ma.us/page554968.html Page 1 of 1 erti icate of Comp Cetion tat* cs Comm ssion Conflict of Interest Law molly Dalton Assists Recreation Activites North Andover Youth Recreation Center i Essex County Employee has comyfeted the Conflict of gnterest Law online training 1(01 rogram onMarch 5 i low Print Close Cerifficate Window Certificate Uj o 37- c�U-; W -- _ C:Q N 6/14/2016 Certificate Ce? ' ate eComykdon Stet# s Commission Conflict of Interest Law Rebecca L nn Duc6esneau Soc ial Studies Teacher,y North Andover Middle School North Andover Public Schools North Andover has compkmd tfie Confxt of Interest Law A�`�y�s � S,`'�� online training,program on w fry 6/14/2016 low Close Certificate Window Cm o aC:) C- � ---t--s C', w OD nt TOWN OF NORTH ANDOVER Z5/ -z0,� VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): Over 18 years of age Under 18 years of age (Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees,I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of T wn Officials. Committee/Department Approval Date titeer Signature D to Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunte r Contact Information Emergency Contact Information Name Name 9heym' OA4 Street Address Street Address Aw�40 � 04% City, State,Zip Code City, State,Zip Code Home Phone Number Home P one Number (w� q(�-�330 A d Cell Ph8ne Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number 6/27/2016 Certificate Ce.?*atv eComykdon cs Commission Conflict of Interest Law i has complewd the cmff&t e gnurest Law o fim trainingyrogram on = %_ y � { 6/27/2016 �� S 5 Print Close Certificate WindowI� CertificateA Sabi F0�'�.t�d hUp://www.muniprog.eth.state.ma.us/page554968.html 1/1 / 11/28/2016 Certificate Certif irate of state S commis sion Completion Conflict of Interest Law Anna Fowler Recreation Staff Member Youth and Recreation Services North Andover has completed the Conflict of Interest Law f online trainingg program on 11/28/2016 PrintClose Certificate Window Certificate �aw — t - LLJ N http://www.muniprog.eth.state.ma.us/page554968.html 1/1 414=6 Certificate Y : erttfi� t� of Comptet,on State Ica Comm. sion Conflict of Interest Law Deborah Fiorillo Departmental Assistant bafs completeb the CoMict of Intere.5t R Atro ,w .% online training program on 4/4/2016 `'. '~. w � F ±-AOGNY H_La0 3 OS T Wd s t hftn•/A&mw ruininrnn Pth.qtntP.ma.us/mne554968.htm1 1/1 Certificate 5/23/16, 7:09 PM 2016 MAY 31 PM f 10 Certiht"trw,Y'r . f, ComyCenon cs Commission Conflict of Interest Law James Patric Frank Skate Guard North Andover Youth Center Y North Andover has completed the Conf ict of gnterest A..� Law 7 online trainingIrq�ram on May 231 Print Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.htmI Page 1 of 1 I Certificate of 3 Su '`o, Sion Co letion Conflict of I terest Law has completed the Conflict of Interest Law online training program on 11/21/ 016 Print CeitiGcatb P.a CD _ N - tL) F3 W Certi f icate of !vM s Comm ssion Co I et'on Conflict of Interest Law Vincent Paul Griseto, Jr. Teacher North Andover Public Schools North Andover i has completed the Conflict of Interest Law = I f `1 online train rogram on I 8/16/ 06 PrintWindow Cerditgite w CO a L.1 n::x .n t-' o F JUN -i PM 2: 52 7- Certiftcate of Co Qit A us r � V s Comte ssion Conflict of Interest Law 3filrian Ooob Counselor Town of North Andover Youth and Recreations Services Essex County Employee bao tompleteb the Conflict of 3fntereot ZaW online training program on i 5/24/2016 \'SS Print," Window Certificate /2016 Certificate t Certift'rate of Completton Stave cs Comm scion Conflict of Interest Law , PLUMBING INSPECTOR TOWN OF NORTH ANDOVER S ba,q completeb the Conflict of lutere.5t Kai online training program one 8/4/2016dss Print Close Cer-tificate Window er#ifica http://www.m uni prog.eth.state.m a.us/page554968.htm I 1/1 5/11/2016 Gerti icate Certif ' rate of �Comptetton ' rtacls s Commt Ris on Conflict of Interest Law 3 Tara jourtep Administrative Assistant DPW / Water Treatment Plant Town of North Andover bay completeb the (Conflict of Intervo KaW f online training program on � 5/11/2016 f Print "Close Certificate `Window ' Certificate N � d � an O c: s+• rstTiCID N00 {") 1H hHn•//www mt minrm ath ctatw ma i is/nanarirW-iA htmi 9/6/2016 IMG_0453.JPG tw'r'�"t,r�fi - —icE 2016 SEP -6 AM 9: 36 TO WN OF jTH ANDOV ER CW S""T :c ert icate of Completion Conflict of Interest Law PaulH,u—tchins https://m ai l.google.com/mai I/u/O/#i nbox/156f6f8Oe72dcab4?projector=l 1/1 :ertificate-Internet Explorer http-,//www.muniprog.L-th.state.ma.us/page554968.html Certificate of Completion E ics Commission Conflict o f Interest Law N � :74r. C3� 0 Paul Hutchins Conditional nal local 111,pe toi Building dept orth Andover c' has completed the Conflict of Interest Law online training program on 9 - i 10 y TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): _X_Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees,I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direc 'on of Town Officials. Committee/Department Approval Date Vo r ignature e Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information Gayle C. Heney Ron Zeheb Name Name 134 Rosemont Dr., 134 Rosemont Dr.,North Andover,MA 01845 Street Address Street Address North Andover, MA 01845 North Andover, MA 01845 City, State,Zip Code City, State,Zip Code 978-681-8028 978-681-8028 Home Phone Number Home Phone Number 617-470-0502 Cell Phone Number Cell Phone Number 617-470-0502 Business/Other Phone Number Business/Other Phone Number 6/23/2016 Certificate Certif irate of Completion k i State s Comm ssion I 9 Conflict of Interest Law ftne lobandla Speech Language Pathologist i Franklin Elementary School North Andover Public Schools ljao completeb the Conflict of Intereot RaW online training program on X n Y \ 6/23/2016 Print Close Cerlificate Window Certificate o cr' cn C C http://www.muniprog.eth.state.ma.us/page554968.htmI /� Certificate http://www.muniprog.eth.state.ma.us/page554968.htmi 2016 Juy Pt' 2: 52 Certqkate Of CO n a, P DOVEiz hl1JSET S conflict of Interest La 9-4hil gam Employee North Andover North Andover Municipal has cam fetes fw Ccrn ®Tf4, terest-Law .°&"€. 5/18/201 ti a � 1 of 1 5/18/16,8:57 PM PECEIVC0 1 ERK'S OFFICE of Comykdon �ACHbsETTS Conflict of Interest Law l uc 'KiCco ne Recreation counselor North Andover Youth and Recreational Services ' North Andover has com feted the Conflict of Interest Law I online trainin ram onMa 15,�Iro 1 ss •4� Print t 5111=16 Certificate ,neex jay � P�w"' f 'Certificate of Completion Conflict of Interest Law Oarine Ra3anbjian Teacher North Andover High School North Andover bag completeb the Conflict of Intereot 'La online training program on x 5/11/2016 LLJ Print Close Certificate Window o f - Certifa LLfit: CD L•1�:a >- ►—sue N 1 http:Nwww.muniprog.eth.state.ma.us/page554968.htmi 1/1 Certificate Page 1 of 1 201 10 Certtficate of Completiott Sqt� ics Commission Conflict of Interest Law Ricole Jkxamer NAYRS NAYRS North Andover ba% completeb the Conflict of 3ntereot XaW online training1 grogram on _ ^) 5/25/2016 Print http://www.muniprog.eth.state.ma.us/page554968.htmi 5/25/2016 cer"CeOe FMOVVED Certtf t rade of C 6jWt TOv�,'t� ar, `SU sCom on NORTH ANDO E R hf r`4' Conflict of Interest Law 1pnne R UMM Substitute Teacher i North Andover Public Schools North Andover i bag completeb the Conflict of Interest Kai online training program on j. y � f 8/16/2016 Printk Close Cerlificate Window Certificate V\he- Urnm I bo old - � R M�q 9 httpJ/www.muiprog.etKstate.ma.us/page554968.htmI 1/1 Summary of the C(A,,._ +cipated in a matter as a municipal employee,you cannot ever be paid to work on that same matter for anyone other than the municipality, nor may you imeone else,whether paid or not.The purpose of this restriction is to bar former employees from selling to private interests their familiarity with the facts of ,,:ular matters that are of continuing concern to their former municipal employer.The restriction does not prohibit former municipal employees from using the expertise acquired in government service in their subsequent private activities. Example of violation:A former school department employee works for a contractor under a contract that she helped to draft and oversee for the school department. (b)One year cooling-off period. For one year after you leave your municipal job you may not participate in any matter over which you had official responsibility during your last two years of public service. Former municipal employees are barred for one year after they leave municipal employment from personally appearing before any agency of the municipality in connection with matters that were under their authority in their prior municipal positions during the two years before they left. Example:An assistant town manager negotiates a three-year contract with a company.The town manager who supervised the assistant, and had official responsibility for the contract but did not participate in negotiating it,leaves her job to work for the company to which the contract was awarded.The former manager may not call or write the town in connection with the company's work on the contract for one year after leaving the town. A former municipal employee who participated as such in general legislation on expanded gaming and related matters may not become an officer or employee of,or acquire a financial interest in,an applicant for a gaming license,or a gaming licensee,for one year after his public employment ceases. (c) Partners.Your partners will be subject to restrictions while you serve as a municipal employee and after your municipal service ends. Partners of municipal employees and former municipal employees are also subject to restrictions under the conflict of interest law. If a municipal employee participated in a matter,or if he has official responsibility for a matter,then his partner may not act on behalf of anyone other than the municipality or provide services as an attorney to anyone but the city or town in relation to the matter. Example:While serving on a city's historic district commission,an architect reviewed an application to get landmark status for a building.His partners at his architecture firm may not prepare and sign plans for the owner of the building or otherwise act on the owner's behalf in relation to the application for landmark status. In addition,because the architect has official responsibility as a commissioner for every matter that comes before the commission, his partners may not communicate with the commission or otherwise act on behalf of any client on any matter that comes before the commission during the time that the architect serves on the commission. Example:A former town counsel joins a law firm as a partner. Because she litigated a lawsuit for the town,her new partners cannot represent any private clients in the lawsuit for one year after her job with the town ended. This summary is not intended to be legal advice and, because it is a summary,it does not mention every provision of the conflict law that may apply in a particular situation. Our website, htto//www.mass.gov/ethics contains further information about how the law applies in many situations.You can also contact the Commission's Legal Division via our website,by telephone,or by letter.Our contact information is at the top of this document. Version 6: Revised May 10, 2013 e•••t....i..e r lk ACKNOWLEDGMENT OF RECEIPT I n Kman employee at r •�! � �7 (C hereby acknowledge that I received a (fir t and last name) (name of municipal dept.) copy of the summary of the conflict of interest law for municipal employees,revised May 10,2013,on (date) http:/twww.mass.gov/ethics/education-arnd-training-resources/implementatior>procedures/municipal-employee-summary.htm1 5/6 ` Q NoerH 9 /� O to e•�O 'W^ Cyt`:��� l rR ��SSACHUSEt�h 21116 JUL 20 AN 11.- 45 TOWN OF NORTH ANDOVER TOWN g,- �GS C� (,� tOFFICE OF THE TOWN CLERK ANDbVEt "A"SlAhCH120 MAIN STREET "`" ' NORTH ANDOVER, MASSACHUSE'ris 01845 Joyce A.Bradshaw,CMMC Telephone(978)688-9501 Town Clerk Fax (978)688-9557 E-mail ibi•adshawtii�towiiofnorthandover.coiii Mandatory Trainiwiq 85 r and ftline Train"Im"'q Chapter 28 of the Acts of 2009, the ethics reform law, imposes mandatory education and training requirements on public employers and public employees (including anyone who serves on a Board or Committee). The law authorizes the Commission to establish procedures to implement and ensure compliance with these requirements, and these Implementation Procedures are issued pursuant to that authority. The requirements can be summarized as follows: Each year, every state, county, and municipal employee must be given a summary of the conflict of interest law prepared by the Ethics Commission and, every two years; they must complete an online training program prepared by the Commission. All records of compliance with these requirements must be retained far 6 years. These requirements apply to all public employees, as defined by the conflict of interest law summarized on the preceding pages. Former public employees are not subject to these requirements. For more information on Ethics you may visit Commission's website, ww,,v.naass•gov ethics. Mandatory educational requirer> ekgt6 �,ubde Compliance Deadlines for summaries: Every public employee must be provided with a summary of the law within 30 days of becoming such an employee, and annually thereafter. Employers must distribute the summaries to all current employees each year by the end of December. Each employee must provide to his or her employer, as defined herein, an acknowledgment of receipt(pg.12) within ten (10) business days of receipt of the summary. Compliance deadlines for Online Trainin�_IProram: Employees need to complete the State Ethics Commission's new conflict of interest law online training program within thirty days of employment and then again every two years. You must complete the online training and send certificate of completion to me no later than November 16, 2015 in order to be in compliance. t 2016 MAY 31 P 1: 0 Oev*�,. : F NORTH � ���'� Cap lion 1 ACt USETTS Conflict of Interest Law Counselor North Andover Youth Services State Employee o kw.,t/wl zi 2�,1wWIYUYL Orb May 22, 2016 Print Certificate http://www.stateprog.eth.state.ma.us/page554968.htm1 5/22/16,11:00 PM Page 1 of 1 ♦s a L!.r. s ti.�t}i r._�+r r.. w i. 1S, ,. w �`S':V:.. w . .��. r t..+• 2016 MAY 31 PM 1: 10 � t { Certtf tcacte t f M� State Ethics Commission ► i fly' 1_v' ftlarplHargaret 'imp Lifeguard r'r Stevens Pond < . North Andover Youth Center +' bay completeb the Conflict of 3ntereot T_atn online training program on F l .+ 5/10/2016 r. A. <i.. ..1.--?'ia �._v - isi.. - _ - of _ �_F ;;4:,'t }-w ..__ 'L•t.. �.-. 'ir+^� ..�_ r� Print Certificate TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): yon Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason, medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with tWifOff i ls.Committee/Department Approval Date e Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information llo b C;U�� Leo�,Z C¢, kJ� row s�; S aLcse) Name ( Name J qZ 5 Street Address Street Address tit . A-, ko,. M c i &Lf5 ram. acnkoe" Mil City, State,Zip Code City, State, Zip Code 9TR 7-S9 2 ct-� 9 z-s S- 6-Lf 122 Home Phone Number Home Phone Number -7 g ( 5 Z.(o u,(o 4 01 a33 6-7 5" � �� Cell Phone Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): V Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Offi 'a ��7-7 ) b Committee/Department Approval Date o unteer re Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information burn ,KU J�OQn� Name Name g-ram{c w Street Address Street Address An &&aq OX OVIYTS City, State,Zip Code City, State,Zip Code Home Phone Number Home Phone Number ��►- SZl — GSSZ Cell Phone Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Officials. Committee/Department Approval Date V unteer Signature Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information Name Name 40 n n� S� Sc,,- Street Address Street Address S� lrn e City, State,Zip Code City, State, Zip Code q---q �-" b t � U-� - (p 13 Home Phone Number Home Phone Number Cell Phone Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number { TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): X_Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Officials. Committee/Department Approval Date Volunteer Signature Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information cde n' N i of avi David V. DeInnocentis Name Name 901 Alder Way Street Address Street Address North Andover,MA 01845 City, State,Zip Code City, State,Zip Code 978-258-6901 Home Phone Number Home Phone Number 978-494-2991 1, vo 1 Q t,(e,c Cell Phone Number Cell Phone Number 6m, ew N.14' Certificate 11/22/16, 3:44 PM . ..f" . .E"''4111Sal 2016 PLOY 29 Ali 9: 4 1 Certi " ate of Comp ktion cs Commission Conflict of Interest Law gLfexandra Mezzina Registrar North Andover has completed the Conf ict of gnterest Law i � online trainin rogram on p 11/22/ Cj 16 Print Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.htmI Page 1 of 1 a�. r, �. .k .►_ .. ._. ,. AOk Certifiracte of (tompletion State ics Commission Conflict of Interest Law -'utie jHoreau Teacher Thompson Elementary North Andover Public Schools bao rompleteb the Conflirt of Intereot labo online training program on = 8/2/2016 Print Close Certificate Window Certificate Certificate http://www.muniprog.eth,state.ma.us/page554968.html 2016 JUN 16 PM 2: 31 Certificate of �COM Yietton'D O-RTH AN 'OVER sac Cam+ scion MASSACHUSETTS Conflict of Interest Law 3'ahob A.abigan Referee Youth Center North Andover bay compieteb the Conflict of Rteregt labs online training program on y 6/15/2016 '6. p 1 of 1 6/15/2016 11:38 AM C rtificate 8/24/16, 12:27 PM 2016 SEP -7 AM 10= 33 Certi " ate oj con, btion , i staw S Con On Conflict of Interest Law Mar aret MottoCo Part time staff member N.Andover Youth and Recreation Services North Andover 9 has completaf the Conf ct of gnterest Law f � online trainin pro ram on r August 2 , 20�6 ' ` '� Certificate Page I of I Certiftra.te of Completion Commission Conflict of Interest Law 41bWarb AtMermott Substitute Instructional Support Staff North Andover Public Schools North Andover bag completeb the Conflict of 3nteres;t 3EaW online training program on 2/24/2016 F��• is�� Print Certificate http://www.muniprog.eth.state.ma.us/page554968.html 2/24/2016 LeMticate ; L. y I 11i I� r 1 rr7rho, F cettftatc of comyCWon { � h f 1t41t.yr '11A�6u��1I1 i;: 3�t�F1',. r Conflict of Interest Law { s} 1 ' P . r r � i f i CYN CD X- CA 1 l has com Ceftd the Con id of gntmest law ���� 7,. o C' CDC onCine training grogram on 7 10/4/2016 tl 1. f li c> i il , *'=<"''J�mr�a}muwkiur,ia;�y4mwaW'. http:.,'NvN"v.munipro;.eth.state.ma.us/page544963.4tm1 lit Summary of the Conflict of Interest Law for Municipal Employees Page 5 of 6 Example of violation:A former school department employee works for a contractor under a contract that she helped to draft and oversee for the school department. (b)One year cooling-off period.For one year after you leave your municipal job you may not participate in any matter over which you had official responsibility during your last two years of public service. Former municipal employees are barred for one year after they leave municipal employment from personally appearing before any agency of the municipality in connection with matters that were under their authority in their prior municipal positions during the two years before they left. Example:An assistant town manager negotiates a three-year contract with a company.The town manager who supervised the assistant,and had official responsibility for the contract but did not participate in negotiating it,leaves her job to work for the company to which the contract was awarded.The former manager may not call or write the town in connection with the company's work on the contract for one year after leaving the town. A former municipal employee who participated as such in general legislation on expanded gaming and related matters may not become an officer or employee of,or acquire a financial interest in,an applicant for a gaming license,or a gaming licensee,for one year after his public employment ceases. (c)Partners.Your partners will be subject to restrictions while you serve as a municipal employee and after your municipal service ends. Partners of municipal employees and former municipal employees are also subject to restrictions under the conflict of interest law.If a municipal employee participated in a matter,or if he has official responsibility for a matter,then his partner may not act on behalf of anyone other than the municipality or provide services as an attorney to anyone but the city or town in relation to the matter. Example:While serving on a city's historic district commission,an architect reviewed an application to get landmark status for a building.His partners at his architecture firm may not prepare and sign plans for the owner of the building or otherwise ad on the owner's behalf in relation to the application for landmark status. In addition,because the architect has official responsibility as a commissioner for every matter that comes before the commission,his partners may not communicate with the commission or otherwise act on behalf of any client on any matter that comes before the commission during the time that the architect serves on the commission. Example:A former town counsel joins a law firm as a partner.Because she litigated a lawsuit for the town,her new partners cannot represent any private clients in the lawsuit for one year after her job with the town ended. This summary is not intended to be legal advice and,because it is a summary,it does not mention every provision of the conflict law that may apply in a particular situation.Our website,http://www.mass.gov/ethics contains further information about how the law applies in many situations.You can also contact the Commission's Legal Division via our website,by telephone,or by letter.Our contact information is at the top of this document. Version 6: Revised May 10,2013 .................................... ACKNOWLEDGMENT OF RECEIPT an employee at/v C• � ,do V,,r (V C' r C 5C 400'J hereby acknowledge that I received a (first and last name) (name of municipal dept.) 1, copy of the summary of the conflict of interest law for municipal employees,revised May 10,2013,on (date) Municipal employees should complete the acknowledgment of receipt and return it to the individual who provided them with a copy of the summary.Alternatively, municipal employees may send an e-mail acknowledging receipt of the summary to the individual who provided them with a copy ofit. State Ethics Commission Web Feedback State Ethics Commission Site Policies Contact Us http://www.mass.gov/ethic s/education-and-training-resources/implementation-procedures/... 2/24/2016 PCL.'rnM-K 04, ?pV— RECEIVE[) 4�'& CU at r Version 6: Revised May 10,2013 2016JUL2045 --------------------------------------------------------------------------------------------------------------- To i�j�Ut MA�� V TES ACKNOWLEDGMENT OF RECEIPT / !_ SL I,_O—tAn n a. ,an employee at�STL,L`e`7 3 hereby acknowledge that I received a copy of the summary of the conflict of interest law for municipal employees,revised May 10,2013,on date) Municipal employees should complete the acknowledgment of receipt and return it to lite individual who provided then with a copy of the summary.Alternatively,municipal employees may send an a-mall acknowledging receipt of the summary to the individual fvho provided them ivith a copy of it. 12 Certificate Page 1 of 1 2016 JUN-2 PM COM-_Itl to of ' Co letion Conflict o I terest Law Mitchell McQuate Assist staff with recreation activities Youth and Recreation Services North Andover has completed the Conf l ict of Interest Law a online trainin Frogram on v 5/19, 6 c' ssdK Af Print ; ' Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.html 5/19/2016 5/21/16,12:26 PM Certificate 2916 JUN -2 PM ! 45 Certfic ate o comn AAAi✓h�3SETTS Commission Conflict of Interest Law Jason Manke Joseph Walsh Basketball Referee North Andover Youth Center State Employee has compCeted the Conf rict of 7 nterest �-- Law online training program on May 21, ZOIb y 6Ss PrintClose Certificate Window Certificate http://www.stateprog.eth.state.ma.us/page554968.html Page 1 of 1 2016� 31 Fri 10 Ce au COMY State ics Commission # I t Conflict of Interest Law %kxander D Niffer f . has compCemd the Conflict of 1ntur-est law onCine training grogram on x 5/26/2016 Ap Print F Close Cerlificate Window Certificate 5/12/2016 Screen Shot 2016-05-12 at 8.38.59 PM.png look AI MAY 31 PM 1: 10 . _ . ate of Comykdon State cs Comm s%ion Conflict of Interest Law 90ina Maw& Lifeguard Youth and Recreation Servies i North Andover has com kted the Con act of Interest Law online training,program on 1 5/12/2016 l 'Whim LISP ie low https://mail.google.com/mail/W0/Mnbox/154a78e4939f2453?projector=l 1/1 OFFICE 2016 MAY 2: 43 TO Certif icacte of Complet 'toll 1.4 T a 5aa cap , Conflict of Interest Law Cbrteltne AcQUbtnep Administrative Assistant Information Technology Town of North Andover jag completeb the Conflict of Nteremit latm ���y�S_ILI\ online training program on Fft 5/10/2016 Print Close Celtiticate Window Certificate 4"ZU113 t-eruncare • Iv€o r; •s r ICE 24 —3 AM 10: 44 ( INN OF r i i xt to of CompletionA"° � �Ce ift�a f State ics Commission Conflict of Interest Law Amp 1. -Mr Cartbp Crossing Guard Police Department Town of North Andover 1ti^ bad completeb the Conflict of Interest labi -- online training7 program on 4/6/2016 PrintClose Certificate Certificate Window hHn•lhuunu m,�ninrr.n n14+c�o4c.m�i�c lnv.o�FAOG`.R Mml 1H 1/31/2016 Certificate r ` 016 FEB - I P l 1: 4 7 Certiffrate of Completion FTh ANDOVER State ssCommtssion 4A"SSACRUSETTS { Conflict of Interest Law z ,41r.z. Kinba fH• Ar3pugb Board of Registrars Board Member North Andover Board of Registrars ` Town of North Andover North Andover MA bd� compreteb the Conflict of !fitere�t Kahn M�~ s����� online training program on 1/31/2016 `'`s53.�t ��•�� MW Print Close Certificate Window Certificate http://www.m uni prop.eths Late.ma.us!page554968.htmI 1/1 North Andover,MA Boards&Committees System http://northandovermaboards.vt-s.net/newcaf.php NORTH ANDOVER Massachusetts Boards and Committees Information S s)_tem Notice of Mandatory Conflict of Interest Law Requirements Main Menu Boards &Committees Members New Volunteer Form Reports Volunteer Form Good Government Starts with You Please enter your personal information Name:*First: ddl: Last: Home Address: Street (NumberCity State Zi p:/y��/ ;41 Mailing Address: Street S /Same as Home Address(Number&Name): Address Line 2: City State Zip: Phone Numbers: --Select One-- At least 1 Phone Number 9 � Should be provided© Email Address: o'y�N' mL0 Q/J�j/'1� 42� Current Occupation/Current /1�,(/ ,�,// Employer: / _T�/t''�CL /„ Narrative:Please tell us how much time you have available and any p `y education,experience or special skills that may be relevant`,.;/,el v—zu.5�`o�O .�/��G, �1 r�lD OD J�✓ to the Committee(s)}you are interested in. � 0 urre�f/ �6 t6ono��,fo�- =a��der'w- i-`Dr= yt P ,tnr%qg 6114 /)�7047�,b tf� _&O�7y lease select the Boa d(s)and/or C'bmmittee(s)that ybu are interestedWn servidg on:(Limit 5 per application) indicates that a Board/Committee consists of elected officials.(Please contact the Town Clerk for information on thesepositions) rj AFFORDABLE HOUSING TRUST ANIMAL INSPECTOR __.. El AUDIT COMMITTEE n, BOARD OF ASSESSORS m BOARD OF HEALTH n BOARD OF REGISTRARS B CABLE TV ADVISORY COMMITTEE n COMMISSION ON DISABILITY ISSUES 0 Vacancy) I^ COMMUNITY ACCESS&MEDIA BOARD OF DIRECTORS n COMMUNITY PRESERVATION COMMITTEE CONSERVATION COMMISSION in CONSTABLES COUNCIL ON AGING n CULTURAL COUNCIL ELDERLY AND DISABLED TAXATION FUND COMMITTEE n EMERGENCY MANAGEMENT AGENCY FESTIVAL COMMITTEE(3 Vacancies) ® FINANCE COMMITTEE GREATER LAWRENCE COMM.ACTION COUNCIL GREATER LAWRENCE SANITARY DISTRICT COMM. ® GREATER LAWRENCE TECH HS DISTRICT REP HARBOR MASTER L HISTORICAL COMMISSION ® HOUSING AUTHORITY ri INDUSTRIAL DEVELOPMENT FINANCING AUTHORITY (2 Vacancies) LIBRARY TRUSTEES LICENSING COMMISSION tj MERRIMACK VALLEY PLANNING COMMISSION MUNICIPAL COALITION FOR AFFORDABLE HOUSING REPRESENTATIVE in NEIGHBORHOOD CONSERVATION DISTRICT COMM. n OLD CENTER DISTRICT COMMISSION n PATRIOTIC OBSERVATION&MARCHING COMM. (2 Vacancies) r, PLANNING BOARD n POET LAUREATE POET LAUREATE COMMITTEE (2 Vacancies) n REVENUE/FIXED COSTS REVIEW COMM. ri SCHOOL BUILDING COMMITTEE SCHOOL COMMITTEE SELECTMEN STEVENS ESTATE BOARD OF TRUSTEES I"7 SUBURBAN COALITION LIAISON (1 Vacancy) t7 SUSTAINABILITY COMMITTEE (6 Vacancies) TOWN MODERATOR El UTILITY ABATEMENT REVIEW BOARD r. WINDRUSH FARM STEERING COMMITTEE (2 Vacancies) YOUTH&RECREATION COUNCIL (1 Vacancy) 1 of 2 4/8/2016 12:02 PM Certificate 1/18/16,7:481 2016JAI22 AM8= Q ` er*ate Of COMAdfi* s Comm ssion Conflict of Interest Law George Odeff Teacher North Andover Public Schools North Andover has cornpfeted the Conf Pict of Interest Law online trainin .progAram on y January1 , 2R6 Print r Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.html Page 1 of 1 hPM:. Certif icate of 7 �. State Ethics Commission Completi on {� Conflict of -ii ,,k.�iest Law 'r ' Rebecca Oldham 44t`1 {+ Staff Planner ':_ N \` =' Planning Town of North Andover �V Yam. has completed the Conflict of r, Interest Law ;'; online training program on 2/8/2016 { f i t . Print Certificate MAY 23 AM Certificate Of 11€l ,Tk A DOV tat* ics Commission Co letion Mfifi c ET Conflict o terest Law Alex Otis Svcc�cc�Q fZ Laborer Department Of Public Works i Town Of North Andover has completed the Conflict of Interest Law ' online training program on i, 5/21/2016 Print Close Certificate Window Certificate j nC fdt�q� 0C :1 old £Z AVN 910$ 14 49 a.}48 3 7 i�-�,�.1 03A13�3 TCF r CLERK'S GFFI-C 20 6 JUG h' Or mate Et ics Commission F:'OR H ANDOVE MASSACHUSET S Conflict of Interest Law Employee North Andover Youth & Recreation Service North Andover hicm cwWwat1w, o�r� trauu / �crirL owl s f May 19 2016 Print Close Certificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.htm1 6/19/16,7:28 PM Page 1 of 1 5/31/2016 Certificate RECE Y TM1,% CL ERK'S 4 — AN Certi atr o Com CefC6ftN 8 TUWN OF stet. cs Commission NORTH ANDOV' NASSACHUSE Conflict of Interest Law Yusa PoCanco f North Andover has completed t u Conflict of Interest Law onCne trainiTyrogram on 5/31/2016 � Print Close i .ate WWI t Certificate http://www.muniprog.eth.state.ma.us/page554968.htmi 1/1 .`- ., #asp, �.j: `� -.. >t,f 1 �•. 'a r �:_., �t a.. (. _ .. _ - t 1 �' �4 1 +i'yi'...M1 {�.'y } iF'>r E a.�+' \�t •p�� `:.I� `�'!�• , � r��jl- Certl ate o Com p Cettion �t ' i► i 5*.a:e Ethic=_ .._r-�_ __ Conflict of Interest Law S cane Pensawat x Employee : Town of North Andover Youth and Recreation ► . Services North Andover has completed the Conf ict of Interest Lawr . Jr' J online trainingA ppro ram on November�22, 16 t Print "�,"' w„ =f{ '- ao Certificate LJ p ~ CV v w Certificate of U CS CO Co letion Confli t a► terest Law Me9han Picanco Special Education Teacher North Andover Public School District 1L)OO:n: c :�O North Andover rq - has completed the Conflict of Interest Lawn online training program on 6., 14!?U16 6/15/2016 Summary of the Conflict of Interest Law for Municipal Employees expertise acquired in government service in their subsequent private activities. Example of violation:A former school department employee works for a contractor under a contract that she helped to draft and oversee for the school department. (b)One year cooling-off period. For one year after you leave your municipal job you may not participate in any matter over which you had official responsibility during your last two years of public service. Former municipal employees are barred for one year after they leave municipal employment from personally appearing before any agency of the municipality in connection with matters that were under their authority in their prior municipal positions during the two years before they left. Example:An assistant town manager negotiates a three-year contract with a company.The town manager who supervised the assistant,and had official responsibility for the contract but did not participate in negotiating it, leaves her job to work for the company to which the contract was awarded.The former manager may not call or write the town in connection with the company's work on the contract for one year after leaving the town. A former municipal employee who participated as such in general legislation on expanded gaming and related matters may not become an officer or employee of,or acquire a financial interest in,an applicant for a gaming license,or a gaming licensee,for one year after his public employment ceases. (c) Partners.Your partners will be subject to restrictions while you serve as a municipal employee and after your municipal service ends. Partners of municipal employees and former municipal employees are also subject to restrictions under the conflict of interest law. If a municipal employee participated in a matter,or if he has official responsibility for a matter,then his partner may not act on behalf of anyone other than the municipality or provide services as an attorney to anyone but the city or town in relation to the matter. Example:While serving on a city's historic district commission,an architect reviewed an application to get landmark status for a building.His partners at his architecture firm may not prepare and sign plans for the owner of the building or otherwise act on the owner's behalf in relation to the application for landmark status. In addition,because the architect has official responsibility as a commissioner for every matter that comes before the commission, his partners may not communicate with the commission or otherwise act on behalf of any client on any matter that comes before the commission during the time that the architect serves on the commission. Example:A former town counsel joins a law firm as a partner. Because she litigated a lawsuit for the town, her new partners cannot represent any private clients in the lawsuit for one year after her job with the town ended. This summary is not intended to be legal advice and, because it is a summary, it does not mention every provision of the conflict law that may apply in a particular situation.Our website,htto://www.mass.00v/ethics contains further information about how the law applies in many situations.You can also contact the Commission's Legal Division via our website, by telephone,or by letter.Our contact information is at the top of this document. Version 6: Revised May 10,2013 ACKNOWLEDGMENT OF RECEIPT I, E:76-H QQ :Pi l -AfX.t ) ,an employee at MA T-H &QX\1E f;1 hereby acknowledge that I received a (first and last name) (name of municipal dept.) copy of the summary of the conflict of interest law for municipal employees, revised May 10,2013,on ? (date) Municipal employees should complete the acknowledgment of receipt and return it to the individual who provided them with a copy of the summary.Alternatively, municipal employees may send an e-mail acknowledging receipt of the summary to the individual who provided them with a copy of it. http://www.m ass.gov/ethi cs/educati on-and-trai ni ng-resources/i m pl em entation-procedures/m uni ci pal-employee-sum m ary.htm 1 5/6 TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge thti, I am(check one): Over 18 years of age Under 18 years of age (Parent/Guardian Consent Require: I know of no reason, medical or otherwise, which would prevent me from performing the requiro.� and that I hay,, the necessir, J:i!i I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its emplovees, I will hold the. Town harmless from anv injury to me or damage to my properr ftfflc�qu C�ulr�f�sfi z co a N Pmd, cr 'OA olb� b MA o18 s W� 130 35b� (p 112 30 35D� "?? l -7 60110 O 1/5/2016 Certificate Aw Certi cafe of Comytedon State CS Commission Conflict of Interest Law Cra' q chard In- has com Ceted the Con xt of Interest Law online training program on 1 1/5/2O 1 6CO � n Print Close • r. - 'w Certificate C,, "� Ub 0D 1/1 http://wiw�0 tS�`uni[Aeth.sta /page55d968.html � TT+. - a Version 6: Revised May 10,2013 ---------------------------------------------------------------------------------------------------------------------- ACKNOWLEDGMENT OF RECEIPT I an employee at �ORXIH Ldl L hereby acknowledge that I received a copy of the summary of the conflict of interest law for municipal employees, revised May 10, 2013, on / 13— //�' — - date) Municipal employees should complete the acknowledgment of receipt and return it to the individual who provided them with a copy of the summary.Alternatively,municipal employees may send an e-mail acknowledging receipt of the summary to the individual who provided them with a copy of it. 12 Certificate Page 1 of 1 2016 MAY 31 PM I- I �P��� � �f �DIn�YPYiDIY " MA SSA(, Conflict of Interest Law Rngeta Romano Gate Attendant North Andover Youth & Recreation Service North Andover Youth & Recreation service bay tompleteb the Conflict of jintereot 'KaW �.._ h 1A online training program on 5/19/2016 http://www.muniprog.eth.state.ma.us/page554968.html 5/19/2016 Certificate 5/18/16, 8:46 PM 2016MAY 31 PH I: i I Ce ' -, ComyCetion Statt ics Commission Conflict of Interest Law Jessica Rosent(iaf Gate Attendent NAYRS North Andover has completed the Confict of gntfrest Law f. online training ro ram on pp Y May 18, 10 J , y Prins" .. ,ertificate http://www.muniprog.eth.state.ma.us/page554968.htmI Page 1 of 1 5/12/16,10:11 PM Certificate 2016 MAY 31 PIS 'y o Com kuon Caio SA ,� ' p State cs Comm ssion Conflict of Interest Law 9homas Regan i Lifeguard NAYRS/Steven's Pond Town of North Andover has commyfeted the Conflict of 2nterest Law J online trainipfroAram on May 1 , bys _. r Print Close Cerlificate Windoww Certificate http://www.muniprog.eth.state.ma.us/page554968.htmI Page 1 of 1 F{ T, or Completion ertiff�'� e p �4��ii Sum* Co Conflict of Interest Law Mayara Reis has completed the Conflict of Interest Law online training program on 5/20/2016 �'`'`ss 1 . •"' Print Close Cenificate Window Certificate http://www.muniprog.eth.state.ma.us/page554968.htm1 A�, Certif irate of SU`. ,e:Comm„Baian Co letion Conflict o terest Law Suman Reddy Teaching Assistant North Andover Middle School North Andover has completed the Conflict of Interest Law ti 7 online training program on y 2/23/2016 J` PrintClose-Certificate Wiii'i' Certificate ,v rTj ry � 1 of 1 2/23/2016 2:37 PM t-enmcaie rage i or i. 2819 JAN -2 PM 1 44 TO WN Cr .� Certtftrarte of Completton TH APO _Toapb R *Ergt Chairman Council on Aging x� North Andover, MA bao completeb the Conflict of Interest T.abrJ online training program one 12/27/2016 f T Print Certificate http://www.muniprog.eth.state.ma.us/page554968.html 12/27/2016 1010>(A TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one): Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees,I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Officials. Committee/Department Approval Date Vuntber Signature Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Informatioonnj Emergency Contact Information Voce'eh ��/yips ✓/C �o �y �y(�vl Name Name Street Address Street Address y /Ll„ or�'Su alei u!a �1.9 0/f City, State,Zip Code City, State,Zip ode YAP - 740'-/ �? ),-> Y?,f - ash- 4 ?21 Home Phone Number Home Phone Number ,S y<P-.2 6s:�o `16 �17,J-, - yJ 2 - o S/� Cell Phone Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number 5/30/16,12:52 PM Certificate i Certi " t , ; Com Cenon com ssion MACJ�J Conflict of Interest Law David Sciaudone Summer Fun Counselor North Andover Youth and Recreational Services State Employee has com feted the Con ict of Interest Law ' online training ro ram on }}` A f May 30, 101b Print Close CCertificate Window Certificate http://www.stateprog.eth.state.ma.us/page554968.htmI Page 1 of 1 5J10 016 Certificate r,�.Cp EIVED t} C!_rp' K'S OF'CE Certificat 2016 MAY 31 PM •Comm •ion Conflict of TO °' G NORTH At�L04'w 4,SSACHIAETTS bag tompletea the Conflict o online training proi, 5/20/2016 Certificate Page 1 of 1 Certif icate of Completton Scats :cams slog Conflict of Interest Law rebecca Otarr Receptionist North Andover Youth and Recreation Services North Andover bao compieteb the Conflict of NtereOt Kato online training program on =� J 7 9/8/2016 PF "Print , G N t 'D http://www.muniprog.eth.state.ma.us/page554968.html 9/8/201.6 Certificate Page 1 of 1 ertificate of Completion NSUOUBCksi" Conflict of Interest Law Anastasia Tsipakis title 1 aide North Andover Public Schools North Andover has completed the Conflict of Interest Law online training program on Fly Thursday, November 10, 2016 Certificate CD ;7 C- C=) - CV http://www.muniprog.eth.state.ma.us/page554968.html 11/10/2016 ?JP=16 Certificate r Certificate of Completion Stag ics Commisslon Conflict of Interest Law i.irbeue Torpep Long Term Substitute Teaching Assistant North Andover Public Schools I Town of North Andover bag completeb the Conflict of Interegt Lab, online training program on v 6 2016 2�2 � �r a hftpJMww.muniprog.eftstate.ma.us/page554968.htmI �/� This summary is not intended to be legal advice and, because it is a summary, it does not mention every provision of the conflict law that may apply in a particular situation. Our website, http://www.mass.Rov/ethics contains further information about how the law applies in many situations.You can also contact the Commission's Legal Division via our website, by telephone, or by letter. Our contact information is at the top of this document. Version 6: Revised May 10, 2013 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ---------------------------------------------------------------------------------------------------------------------- ACKNOWLEDGMENT OF RECEIPT I, � ,an employee at hyy1(f NU(T� A-n&QVC( hereby acknowledge that I received a (first and last name) (name of municipal dept.) copy of the summary of the conflict of interest law for municipal employees, revised May 10, 2013, on date) Municipal employees should complete the acknowledgment of receipt and return it to the individual who provided them with a copy of the summary. Alternatively, municipal employees may send an e-mail acknowledging receipt of the summary to the individual who provided them with a copy of it. Certificate Page 1 of 1 Certtfirate of Completion Stan CS Comm SSion Conflict of Interest Law fRitbad Ottrep Social Programs Coordinator North Andover Youth and Recreation Services North Andover bao completeb the Conflict of IntereOt ZaW ��"�S 9-\ 5�fr online training program on pry 11/3 0/2016 sa►�. �-�s Close Certificate Window r? cw C`1 r� J. .Y http://www.muniprog.eth.state.ma.us/page554968.html 11/30/2016 Certificate http://www.muniprog.eth.state.ma.ug/page554968.htn-A Cierfif t'rate of (Completion Sts oes Comnsission Conflict of Interest Law Rartbleen Varnep Administrative Assistant Public School Department Town of North Andover bay completeb the Conflict of Intereot Rai -" 4, online training program on C:� mn t cz� �5- fV . 7/31/2016 j' ' `�' s 7i�`` W ca Print Close Certificate Window Certificate 1 of 1 7/31/2016 5:26 PM Certificate of State tics Commission COMRIetion Conflict oterest Law Alison Wardwell Partial Inclusion Special Education Teacher North Andover Public Schools Town of North Andover has completed the Conflict of Interest Law online training program on 8/18/2016 Print Close Certificate Window Certificate 114 01 :01 W L- d3S 91OZ Q3Ai304 Certificate 3/8/16 8:17 PM Y z.m ,,� _ w • d. erti icate o Com Cetion I p Stag ics Commission Conflict of Interest Law North Andover Youth Recreation Services has complletedthe Conflict of gnterest Law online training pprogram on March 8 201KV b Print CloseI I Certificate o t.: N Lt._ rtf= LJ U- Ld = LD =.2: F.. N http://www.muniprog.eth.state.ma.us/page554968.htmI Page 1 of 1 Certificate http://www.muniprog.eth.state.ma.us/page554968.htmi N„ 2016 JUN -8 AM 10: Certificate of Complett,9A, s Com ssio� MASSAGHVSE7j S Conflict of Interest Law l[egban Trainor NAYRS Summer Staff North Andover Youth & Recreational Center North Andover, MA S. jag completeb the Conflict of 3ntereot 3EaW ��`': iL online training program on 5/25/2016 1 of 1 5/25/2016 3:41 PM TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(check one Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason, medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Officials. Committee/Department Approval Date Volunteer Signa ure .- Date Signature Gf I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information elm BODY- eu I n Name Name 16 ScPV}�P Street Address Q Street Address City, State,Zip Code City, State, Zip Code Home Ph6ne Number ,,,, ,� ���Z,� Home Phone Number 4 Cell Phone Number 17cj'i �49'6•'VWd Cell Ph6qe Number OLA- Business/Other Phone Number Busines /Other'Phone Number i l TOWN OF NORTH ANDOVER VOLUNTEER SERVICE AGREEMENT I enter into this Agreement to volunteer uncompensated services to my Town and acknowledge that: I am(checkone): V/ Over 18 years of age Under 18 years of age(Parent/Guardian Consent Required) I know of no reason,medical or otherwise,which would prevent me from performing the required tasks; and that I have the necessary skill and ability to perform them. I hereby assume full responsibility for my own safety. Except where resulting from the negligence of the Town or its employees, I will hold the Town harmless from any injury to me or damage to my property and from injury or damage resulting from my own negligence. I will perform the volunteer service in compliance with the direction of Town Officials. Jr—&a7l--� i o/b Committee/Department Approval Date Vol u to Signature Date Signature I give consent for my child to volunteer for the Town of North Andover. Parent/Guardian Signature Date Volunteer Contact Information Emergency Contact Information JoyCL occ 130(-!:LJ M i Ci4�L-� ao L Name Name i b 3 OLI) -F�4km RDAD S/4 HI Street Address Street Address 146 lgA11�u��� �-1H s (4 City, State,Zip Code City, State,Zip Code 978- 6&3 , '-f ;4h-c-E Home Phone Number Home Phone Number 6) 7 • �'43 , 7693 Cell Phone Number Cell Phone Number Business/Other Phone Number Business/Other Phone Number