HomeMy WebLinkAbout785 TURNPIKE STREET (�l 8
`? n Department of Fire Services
Office of the State Fire Marshal
P.O.Box 1025,State Road,Stow,MA 01775
CERTIFICATE OF REGISTRATION
North Andover April 30,2019
(City or Town) (Date)
NOTE:Complete top and bottom of form and forward both sections and fee to local Licensing Authority(City or Town Clerk).
DO NOT RETURN FORM TO THE DEPARTMENT OF FIRE SERVICES.
In accordance with the provisions of Chapter 148, Section 13,of the General Laws,the undersigned hereby certifies that:
(TITLE HOLDER): BP
(ADDRESS): 785 Turnpike Street
is the holder of the license granted(Date): 2/3/1973 for the lawful use of the building(s)or other
structure(s)situated or to be situated at (ADDRESS): 785 Turnpike Street
NORTH ANDOVER, MA 01845
(City or Town)
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
NOTE: This certificate of registration must be signed by the holder of the license if said license was granted prior to July 1,1936,
Otherwise by the owner or occupant of the land licensed.
Re ' ed2019.........
� a ......................
(O 1 i 'tie) (Clerk) (State whether owner,occupant or holder)
(Address)
1-4
G Services
ent of Fire rsba,
A
,� � pepartm r1j
of the state dire M 01115
w 'd Office 1025,State Ro $tOed, 7
r o.BoX 'GISrVV ATxp Apri130,2�1
yg �FjCATt p rlotth Andover 1pate)
CER (City or T°wn) C%w or Town Clerk).
local Licensing A°tl'oi�r�
V.
forward both sectionsi that:
of form an avid
d ENT aned herehY certifies
and bottom E r ndersia
NDTE: ctTtRET gORNI TU T 1 Laws,the u
Comp the Genera
IIINO Section 13,of
visions of Cha�tcr 148, or other
In accordance wtt}t the pro the buildin�(s}
ER)' BP for
the lawful use of
(TYTLE BOLD 7gg T mpike Street 213119�13
(, DDWSSS) cited(Date). ike Street
license g'a �g}: ?85Ng p 1845
is the holder of the ABLES OR Evi'OSIVES-
situated at (ADD AN�ppV ER, 1,[936,
structure(s)Situated or to NORT or To�'+n) pg FLAMNI ed prior to July
(C�ty LE ra
�ORSA
GE,�WFAOT the holder of the license it said license w ✓
othe EP1I`1O�ST�i ration Must be sign
and licensed• „ #pit''"��►►/►►'r►►►►
as related t wrier or occupant o ,
Nogg: This certificate of r g
n
otherwise by the ow
.1.. .,.2017. .... rill O
R J• ►►l �i►�►
11 '(NA
(Ofl`fcinl Tit/c) GYerkJ ��tp whethero�n�� ►►"''r''���I I I II/'
The Commonwealth ofMassachusefts
Department of Industrial Accidents �
Office of lnvestigatr ins
600 Washuzgion Street
Boston,MA 02111 �
www.mus&gov1Wia
Workers'Compensation Insurance Affidavit: General Businesses } '
Applicant Information Please Print Lezibly
BusineWC)rganization Name:_R.,G, Z
Address:
City/StaWMP: J,, iM Q�-�l� Phone
Are you an employer?Check the appropriate box: Buslne pe(required);
1 iff am a employer with �i _employees(full and/ S. Retail !
ar part-time).* 6. ❑Restaurent/Bar/Eating Establishment
2,❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity. 7 Office and/or Sates(incl.real estate,auto,etc,)
[No workers'comp,insurance required] 8• QNen-profit
3.[] We are it corparatim and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10,Q Manufacturtng
no employees,[No workers'comp.insurance required]* t l.❑Health Care
4,Q We are a non-profit organimtion,staffed by voluntears,
with no employees,[No workers'comp,insurance req.] 12.E]Other
*Any applicmit.thal cheda box0l most also fill mn the secuon below showing theirwarkers'compensation policy informoWA,
+'«lf the corporate offioen have exempted ntomschts,but the ca Wrolon bo odwr employeEg,a workers'oompensation policy Is roquired and suoh on
orgmthotlon should cheek box#1.
I a»t an employer float is providing Ivor.kern'compensation insiaraor my employees. Beloit,Is the policy Information.
Insurance Company Name: M to ktr+%J A t XG \XrC 'W
insurer's Address: Q.0. �'O X 2 2
City/Stateaip: Q �0.v�.r^ Vv� bQ 0
'Policy#or Self-ins.Lia# l(f Oo a '3 Z b Expiration Date:_ 5 1 201f°
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)..
Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the Imposition of criminal penalties of.a
line up to$1,5t10.04 andfor one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a fine
Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verifiestion.
I do hemby ce)! , rt tefflors arod penaltled of peryury flirt the Information provided above is true and correct
si attire• / {
Opial ass only. Do not write hi this area,to be canpkted by city or town ofJlelaL
City or Town: Permitll icense#
Issuing Authority(circle one);
1.Board of Health 2.Building Department 3.Clty/I'own Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone 0:
www.mess.gov/die
i
i
,. Department of Fire Services
Office of the State Fire Marshal
P.0,Box 1025,State Road,Stow,MA 01775
CERTIFICATE OF REGISTRATION
North Andover Apri130,2015
(Cityormwn) mero)
N01'E:Complete top and bottom of form and forward both sections aad for to local Licensing Authority(City or Town Clerk),
DO NOT RETURN FORM TO THE DEPARTMENT OF ME SERVIC[+S
In accordance with the provisions of Chapter 148,Section 13,of the General Laws,the undersigned hereby certifies that:
(TITLE HOLDER); HP
(ADDRESS): 785 Turnpike Street
is the holder ofthe license granted(Date):2/3/1973 for the lawful use of the building(s)or other
structme(s)situated or to be situated at (ADDRESS): 785 Turnpike Street
NORTH ANDOVER,MA 01845
(Clryor Town)
as related to the KEEPING, STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
NOTE: This certificate of registration must be signed by the holder of the license if said liceas wasgrnnted dent. lyl,1936,
Otherwise by the owner or occupant of the lend licensed. a
Received .. .,.�.p,` ..�..1...201$._...... .............. . .. . . . _.....
By ...:�.� :fr:1.S.'.5.+.... :(::�.f.�- Q/.O�¢./_............_...Wl.1LG.S;�..
mtsl Tine) (Clerk) (Stetewhede,owaegoecupenterholdw)
785. Tuc . .;. ..........
I7te Commonwealth ofMassaehusetts
Department ofludustnalAccideals
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gouldirt
Workers' Compensation Insurance Affrdaviti General Businesses
Armlicant Information Please Print Legibly
Business/Organizalioa Neme: 1!
Address: l I v� 'aK,
City/State/Zip: h d Phone k:�7P ba�� 1 2�'I' '
rcoa an employers Check lh appropriate box: Busine ype(required):
1 am a employ.with employees(full mid/ 5, snail
or part-time)! 6 E]ReneuranUBaiiEeting Establishment
2,0 lam a sale proprietor or dumarship and have no 7. QOfgce and/or Sales(met.real estate,auto,ate.)
employees working for me in any capacity,
[No workers'comp.insmance required] S. Non-profit
3.0 We are a corporation and its officers have anercieed 9 ❑Entertainment
their right of exemption per o. 152,§1(4),and we have 10.0 Manufacturing
no employees (Na workers'comp,insurance laqu'vad]" I I ❑Heahh Cart
4.F We are a nonprofit otgenlretion,staffed by volunteen,
with no employees.No workers'comp.Insurance mq.] 12.❑Other
-Any oppliesar that IWU boxy I mall elm all poc the senior below showing Neir work.'eompennnan pal lot IrJwm ation.
^If the wrpann omen M1me vemptetl thamselvu,but the r4l.mtian hm nhv rmployees,ewarkns'oompcnsalion pnlivy U«gnimA mtlsuch xn
orypdanlonm.Wdehsekb..1L _
lam"employer l Isproviding wortopil,comp nsaflun lnurancefor my employees. Below fs OiepoOcy hibrnmdon.
Insurance Company Neme: �.
local Ackipm
City/Suta/Zil\ SVa^ V- r' t 12 Z
Policy g m Self-ins.Lie:# Mi ice' �7. )7E Expiration Date:_
Attach copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c, 152 can lead to the imposition of criminal penalties of
fine up to S1,500.00 andtm one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
afore,$250.00 a day against the violator, Be advised that a copy of this statement maybe forwarded to the Office of
investanions of the CIA for msu,2Lm mom momw v ifieation.
I do hereby ided poor.t,true and correct.
Si eNre:
Phone
offlclnl rue onty. Do not,orae la this area,to be comple(erl by city or tmpn olffefa6
City or Town: Permit/Licenee k
leasing Authority(circle one);
1.Board of Health 2.Building Department 3,Chyffown Clork 4,Licensing Board S.Selectmen's Office
a,Other
Contact Person: Phone ti:
www.mes xov/din
s;%":.Fs_ �J/y� {�6f,L..t.dfN♦�EdGLh � ✓lt-U4dfLCrNA4>vvt2
y �C e ✓
Department of Fire Services
h`
3 ' Office of the State Fire Marshal
P.O.Box 1025,State Road,Stow,MA 01775
CERTIFICATE OF REGISTRATION
North Andover April 30,2014
(City or Town) (Dale)
NOTE:Complote top and bottom of form and forward both scctions and he to local Licensing Authority(City or Town Clerk).
DO NOT RETURN FORM TO THE DEPARTMENT OF FIRE,SERVICES.
d accordance with the provisions of Chapter 148,Section 13,of the General Laws,the undersigned hereby certifies that:
TITLE HOLDER): North Andover Getty
'ADDRESS): 785 Turnpike Street
c the holder of the license granted(Date): 2/3/1973 for the lawful use of the building(s)or other
tructurl situated or to be situated at (ADDRESS): 785 Turnpike Sheet
NORTH ANDOVER,MA 01845
(Otyor Tawn)
s related to the KEEPING, STORAGE,MANUFACTURE OR SALE OF FLA MABLES OR EXPLOSIVES.
NOTE: Tho certificate of registration must be signed by the holder of Dm license' raid license w nted prior to July 1,1936,
otherwise by the owner or occupant off o,land licensed. �,
/ p / ��
received ......( 1 :21.EL .......2014......... .. .. . '..(..l%._...�./. ... ... ....._............
/ (SlgnaNN)
sy ....................................... ./dex ......................................
(foul Title) (Clerk) (S�l9to whcNer cer,om occu en hold r)
t5 /gym:/ 7/rn'1
(Addic e)
r,Iti?ea��,�i `�" �adoac�xuav,�(a
Department of Fire Services
Ae Office of the State Fire Marshall
P.O.Box 1025,State Road,Stow,MA 01775
REGISTRATION
North Andover, April 30, 2014
ACWyor Town) (Ddlc)
'Iris is to certify that North Andover Getty
ias, in accordance with the provisions of Chapter 148, Section 13,ofthe General Laws,filed with me a certificate of
egistration setting forth that: North Andover Getty
s the holder of the license granted(Date)2/3/1973
or the lawful use of the building(s)or other structure(s)situated or to be situated at: 785 Turnpike Street
s related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
�(siEnature and Official Tine) Clerk
Note:A ce iPcaN ofs,cura mn most be filed on or before April 30'"ofeach yea.
(THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.)
EXPIRES APRIL 30,2015
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Durso & p 1 1Z=7000 1?
Jankowski BTHMASSACHUSETTS MAVENUE WWWAURSOIANKQW$KLCOM
ER WBp NS skI N I (9)A]bBFJ001 NORTH ANODVEG.MA 01 Bn5
INBU�RARICF
May 2014
R&G Fuel Inc
DBA North Andover BP
785 Turnpike Street
North Andover, MA 01845
RE: Workers Compensation # WCTS517E
Dear Roger:
I am pleased to enclose your Workers Compensation Renewal Policy effective
06/09/14 with NGM Insurance. It is important that you review the policy to
be sure that the coverage is sufficient for your needs. If you have questions
or wish to discuss the coverage in more detail, I encourage you to give us a
call.
We thank you for your continued business and look forward to servicing your
account during the coming year.
Since urs,
Durso & Jankowski Tnsarance Agency LLC
WORKERS COMPENSATION AND EMPLOYERS'LIABILRY
INSURANCE POLICY—INFORMATION PAGE
INSURER: POLICY NO: WCT8517H
NGN INSURANCE COMPANY
4601 TOUCHTON ROAD BAST
SUITE 3400 RENEWAL OF: WCT8517B
JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322
Account No: CACT8517E
ITEM 1.NAMED INSURED AND MAJUNG ADDRESS: AGENCY NAME AND ADDRESS:
R&G FUEL INC DURSO & JANKOWSKI INS AGCY LLC
(SEE NAMED INSURED SHUT)
785 TURNPIKE ST 198 MASSACHUSETTS AVENUE
NORTH ANDOVER MA 01845-6120 NORTH ANDOVER, MA 01845
AGENCY PHONE NO.: (978) 688-7000
AGENCY NO.: 200530
LEGAL ENTRY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule)
ITEM2. POLICYPERIOD: From: 06-09-2014 To: 06-09-2015
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state:
listed here:
MA
S. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of
liability under Pan Two are:
Bodily Injury by Accident: $ 11000, 000 each accident
Bodily Injury by Disease: $ 11000, 000 policy limit
Bodily Injury by Disease: $ 1, 000, 000 each employee
C. Other Stales Insurance: Part Three of the Polley applies to the states, if any, listed here:
all states except ND, OR, WA, WY
and stales designated in ITEM 3A of the Information page.
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals Of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule Is subject to
wrification and change by audit Please see Classification Schedule.
Total Estimated
Minimum Premium: $ 265 Annual Premium: 582
Audit Period: ANNUAL
Date: 05-01-2014 Countersigned by
WC 0001101 A Cepw1911t My rJotlorel Council on Cempe,saon imunnce
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information ^^ Please Print Legibly
Business/Organization Name: v.�y fd- V,C s � e
City/State/Zip j/ tun A V t Q 4 Phone#: q )Y_ 6
Are on an employer?Check the appropriate box: Business Type(required):
l. lemaemployer withemployees(full and/ 5. IQne[ail
orpart-ame)P' 6. ❑RestauranOBo/Eeting Establishment
2.❑ I am a sole proprietor or partnership and have no 7 ❑Office and/or Sales(roc).real estate,auto,etc.)
employees working for me in any capacity. g ❑Nan-profit
[No workers' comp.insurancerequired]
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per e. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers comp.insurance required]' I 1 ❑Health Care
4,❑ We are a non-profit organization,staffed by volunteers,
with no employees.[No workers' comp,insurance rec;1 12.❑ Other
'Any evil lent an checks box N I must Ma fill om the section below showing Ncir workers'compcnsniion policy ir%.1 ion.
-W,he cwvorste roam have«eowwd themxdvn,bul the-,.tion has A,,,employe.,a workers' m,iv aft.n polity is re,u,,d sod such an
cppniration should check box 01.
I am an employer that uprovidup�,q�wor ers'gcampen n/insuranceformy employees. Below is thepolicy information.
Insurance Company Name: /1i� �� Id II �� l �0�
Insurer's Address: '4 6 O `O Y r S
2Z (� j
City/State/zip; �tr C S �� � I
Policy#or Self-ins.Lic,# LV1 (2, ��� � 7 67 _Expiration Date:—
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMOL 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 urance coverage verification.
I do hereby re Iif of th a' d enalt' ofperjury that the information provided above is true and correct.
Siaturc
a "\L Date* �O
`
Phone#� � '— l�— 3 -�
Ofcial use only. Do not rvrite in this area,to be completed by city or town ofciai
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 Office6.Other
Correct Person: Phone#:
www.mess.gov/die
I
�A The Commonwealth of Massachusetts
�\ Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
rvwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Please print Legibly
Applicant Information � p '
Business/Organization Name:_ (;aG- F"'� �/°`t- �--LAN""k'�-CO `'+e�1�6'
Address: "hA a�_✓z s �"` 1 uw+� ojV4 Phone
ba'>_- 12 % �
City/State/Zip:LV. ��-+.� —
F
e you an employer?Checkk thropriate box: Businss'Fype(required)j. grRetail
1amaemployer with employees(full and/ 6. ❑ RestauranUHar/Eating Establishment
or pan sole p*❑ I am a sole proprietor or partnership and have no 7. � Office and/or Sales (ind.reel estate, auto,etc.)
emolevees working for me
in any capacity.
Department of Fire Services '
z
do Office of the State Fire Marshal
y„^
P.O_Bos 11125,State Road.Stow,MA 01775
CERTIFICATE OF REGISTRATION
North Andover April 30,2013
(City or l'mar) (Dn(c)
NOTE: Complete top and bottom of form and forward hulk sections and fee to local Licensing Authonty(C'it) or I ,n Clerk).
DO NOT RETURN FORM TO THE DEPARI'MEN'I OF FIRE SERVICES.
In accordance with the provisions of Chapter 148, Section 13,olthe General Laws,the undersigned hereby certifies that:
(TITLEHOLDER): North Andover Gerry
(ADDRESS): 785 Tumpike Strcel
is the holder of the license granted (Date): 2/3/1973 for the lawfal use of the building(s)or other
structure(s) situated or to be situated at (ADDRESS): 785 Turnpike Street
NORTH ANDOVER, MA 01845
tclry ,, lownt
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
Noll This certificate of registration must be signed by the holder of the license if said bcense was granted prior to July 1,1936,
Oahe wise by di owner or occupant of the land licensed.
b
Received � i'1K1.
Isgnil )
By ......
It r ell tkl fClak) .......(State h'ther U.voer,oei,opaht orholtler)
(Addras>
Services
C�- " ^e Marshal
MA 01775
'RATION
North Andover April 30, 2014
ieay orrnont 1o:ne1
NOTE: D Incnl Liccnsine Amhamc(('... orTosco Clerk 1.
DOO N� 'RVICES.
In accordance with the provisions. undersigned hereby cerlities that:
(11"ILF HOLDER): North Andov
(ADDRESS): 785 Turnpike Street
is the holder ofthe license granted (L .,j for the lawful rise of the building(s)or udher
structure(s) situated or to be Situated at (ADDRESS): 785 Turnpike Street
NOR I IT ANDOVER, MA 01845
(Ci1p or Towm
as related to the KEEPING, STORAGE, MANUFACI URE OR SALE OF FLAMMABLE:S OR f XPLOSIVES.
SO']L This certificate of registration must be signed by the holder of the license its a d Imeioi was .nine far or m July I,19X
f Otherwise by the owner or oceupan[ot the land licensed.
J
Received (I ek4R h-:. '014
.. s ,.� _.__ ....__
y�
�ttm I rhlel (Clerk, .._. ...
(Slnl I Ih [o env � 1 Inca
(Add.... WA Of V4��
-- - - 08953-456-00362-7 34694 261 T
043339793 DO 00 0000 9710 0401
R28590
Department of the Treasury Date of mie nofice: MAR. 17, 1997
Ta a r Idenlitying NUIFI 04-3339793
_- Internal Revenue Service Form Tax Period
pNDOVER, MA 05501
For assistance you may
1..Irl.Irrlrl.Irlrl.. .r,.I..rlrl.11lrl,rllrlr.rrrr,�.rrrl..,..1 call rear
617-536-1040
1-800-829-1040
TURNPIKE AUTOMOTIVE SERVICES INC or yea may wrae to as at
785 TURNPIKE ST the ade,em shown at Me
N ANDOVER MA 01845-6120850 left It you write,be
arse to smash the Bonom
pars of this nobee.
NOTICE OF ACCEPTANCE AS AN S-CORPORATION
YOUR ELECTIDN_SO. BE TREATED AS AN S-CORPIIRATION WITH AN ACCOUNTING PERIOD OF
DECEMBER IS I ACCEPTED.
THE YOUR RE TO EFFECTIVE BEGINNING JAN. 3, 1997, SUBJECT TO
VERIFICATION EXAMINE
IF YOUR EFFECTIVE DATE IS NOT AS REQUESTED, IT WILL HAVE BEEN CHANGED FOR ONE OF
TWO REASONS. EITHER YOUR ELECTION WAS MADE AFTER THE 15TH DAY OF THE THIRD MONTH OF
WHENT SUBMITTEDTWASI INCOMPLETE, AND BREQUESTED INFORMATION T WAS RECEIVED AFTERHAT TAX YEAR, OR THE ELECTION WHCH IT APPLIES, THE FILING
TPERT OD HEREFOREITBEENH TREATED AS THOUGH ITN IS WERE MADEID FOROR THEHE NEXT TAX
TAXYEAR
YEARREQUESTED AND HAS
PLEASE KEEP
THIS NOTICE IN YOUR PERMANENT RECORDS AS VERIFICATION OF YOUR
ACCEPTANCEA
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR THE ACTIONS WE HAVE TAKEN, PLEASE
WRITE TO US AT THE ADDRESS SHOWN ABOVE. IF YOU PREFER, YOU MAY CALL US AT THE I TO
RS
TELEPHONE
HOWEVER, STED IN THE DFFICEUATLOCAL
ADDRESS SHOWNAONE THISEE NOTICE I5MMOSTAY E FAMILIAR
WITH YOUR CASE.
IF YOU WRITE TO US, PLEASE PROVIDE YOUR TELEPHONE NUMBER AND THE MOST RETURCONVENI ENT
TIME FOR US BOTTOM PART OF CALL THIS SO WE
CTO CONTACTHELP US IOU TORESFY OLVEUR LYOUR INQUIRY. PLEASE RETURN THE
THANK YOU FOR YOUR COOPERATION.
To make sure met IRS errployaee give corrteaus responses and salsa informatsu m faI a r eo,md IRS emplayee somehmea listens ar an
Overlay 5 Form SUIS(R.A 91)
telephone calls.
Keep this part for your records
Return this part to us with your check or inquiry
Ya t I ph numb Be t hm t call
043339793 VQ 00 BUGG
INTERNAL REVENUE SERVICE
261 ANDOVER, MA 05501 TURNPIKE AUTOMOTIVE SERVICES INC
785 TURNPIKE ST
N ANDOVER MA 01845-6126850
9710 ,r ",. 08953-456-00362-7
;5 • �� l¢ntrn wt rJea�i � �' d<,��'f�d�tQ
Department of Fire Services
,,. Office of the State Fire Marshal
P.O-Rox 1025, Slate Rood.Stoa,MA 01775
CERTIFICATE OF REGISTRATION
North Andover April 30, 2012
((it,or I ) (Dal')
NOTE: Complete tap mid bottom of form and fonamd bosh seolions and fee to local Licensing Authority (City or loan('lerky
DO NO'I HE I URN NORM '1'0 FHE DEPARTMENT OF FIRE SERVICES
In accordance with the provisions of Chapter 148, Sichon 13, of the General Laws, the undersigned hereby certifies that:
('fffLE I IOLDER): North Andover Getty
(ADDRESS): 785 Turnpike Street
is the holder of the license granted (Date): 2/3/1973 for the lawful use of the building(s)or other
structure(s) situated or to be situated at (ADDRESS): 785 I urnpike Street
NOR'riI ANDOVE,R, MA 01845
tClp ol'Ibxn l
as related to the KEEPING, STORAGE, MANUFACIURE OR SALE OF ELAMMAHLES OR EXPLOSIVES.
NO'1 t. This certificate of registration must be signed by the holder of the license ifsaid I'cense was gran d prior to July I,1936,
Otherwise by the owner or occupant of the land licensed.
7 Received .. .<Cy l� �012 _._. .0.Q . / � __. (s ma )
(011icial Tlc) o "k) (State tmedicrn,.ner.au:upunt Or holder
23�..�. .R ;� rY�/.wF 6t^ wdol8w�
.............
(Addre„)
t
The Commonwealth afMassachusetts
Department of Industrial Accidents
AW=Af sty
600 Washington Street
Boston,Mass. 02177
Workers' Com enaation Iasorance Affidavit-General Business"
R} G OQ ^/
®,loon Rttad Q Retaaaat/Bar/Eatiag Estahlishmem
I am a Mile prop new and have no me Badness 7YPr ❑Office❑Sales(mclnding Real Estate.Antos ete.)
waking in any capamty.
® I am ffi® 1 with em to faB k art time. ❑Other
I am m employs p�o"'d'°6 warkas'comPmsanm far my®ployas amkmg m thisjob.
.em n M
i
I am a sole polatcim'and have hued the independent emtractcrs lusted below who have the fallowing wakes
comPcosahaa Police:
tom D.
.ddren:
M
.ury
coin v.vxr _. .
inmrvv
F.Wre b rrr.r.enOr tagoti
®dr 9rWe 23A.(MGL 132 W N #M.ad rh.l dpv..t Dr vpbal,SN M..L.r
.styr.y.ptymetr vJrefratm•afrbd.lrr.(.670l vaDRtC OYDER.d.dm Halaa.M very epimt:m Imbnb.N tLt.
ty�(tby rbdrvt®yb brv.rdd b th.omm Nlmstlp Wm NtY aGbr r.rn+P^rmrlia
76 Fereby t.W rt e i end r alder^fp.rjrry thartke forratianprsrided absre�h�e a:rd c.ned
t Dets S
sipstere
creme oG,
.di.blvr.:ar Mint naf.in .rrbhe roWww by dty.r b .itiehd
prrvrye.r.x �DeadNa D.p.rtr.vt
eny.r b.n: (]I.fermbe 1berN
❑ehecl:ahvmedi.b r.tp.r.h required �9.iectrm.'r odic.
parish Deprtmeat
ph..x; �Olher
.viers peo..:
t....e sat am1
a G"`a�aa "�
Lj0 l,a"r",Department uC Fa�.`Y¢cMaYS�Ia�
ftv� the State St ,,.ninol ,
`3 pSfi¢eot h ad.�s.vateRa N ATI� APrit3o���t
P.o.e°, pF C,16T[i ith Aodo,
Co
alvicATE NOc,c�n° ^t
�uthoca. �
ytd lcc to\ocst lJC Ss b
i FiµE'fit
n
h 5epioo
nd tor,:ar��iHEtii D t nnders;E°ed
czNCcest a '
it of Corm.` 9E DF.P.
bob.pµnC.ip i\
bete
01 the Genera\lWT
.a��'s,th
UD�II)1R ClRtii o
TE: i, Section \i.
VO
lci \48. hUlklmu�s)
or
oC ChuP
e Kith the P{Outs �awC
ttl nse °t t
! O'tb Andover Gettti for the
In accordant
i\O\.DORF lke Street � 3�1993 Street
FSSP �85 TomP vedpace)'. 85TPrnP;ke �SI�rG.S 6
¢ran SS) p01g45
�ApOR the Gccnsc .. ppRF.
red at l� ND0 FR.M MpOL
FS pRt�l
t the hoAder °ti to be�rtua NpScTH P op FI.PM a Oeense
as rsnre P^ r�J Jat
Oi tit.or'roanl SQL('. Cs
NCWre�s)spry"died \ i�1,F 11Ch der of the\lcease t -...
si .�KnGC.MPthesB^ea°avtre„sea.
� $1 mus elan
dlo the��e pµtlicate oCreB`�rnor oecuPaOt of GL""Tr'+'_" .
as(Gale Thiscer se by the or` .. t5ma,v �`-'c' ti....... Yl•
i.,OCi.: r r,ry.�n
M... rho ... 7�7...........
µeczry FCl^.�tf>ti \a.,x\
The Commonwealth of Massachusetts
-- -- Department of Industrial Accidents
600 Washington Street
Boston, Mars 01111
Worken' COMPe=11&raatt At6davk-General BnvaesseH
�tG ( IL f 7 d r, �.
eddt<sr � ` S i
cti d k . � � W vh N �77�-6YfZi9r
woh site I-ei eddte
❑ I am a Mile ptopritYa and have no one Bndneae Type: ❑oftail t,=❑ltbtamanluding Real state,ishmmt
working in any rapacity. ❑ Ohre❑ SaleM(including Real Estate,An[as ea.)
I am an tm l with � m to fell & err[time . ❑Other
I am en®ploys p"idmg°r�k rs a mPa®M?nm for my®ployaa asking m Wisjo6.
n g
rom
.dareu: 3.. 2
-
el ^44ve, 5 :, l N•. LWIn.(3 :_ '32i7TG 1 _ 7 -oci
I am a sole ptolniear and have hired the indcpendmt contract=listed below who have the following warkca'
Watpeosatiu polices: _
.ddre.e•
N
in.aravee m
rom eadee
inwn (I1�
mdr 9e.We 23Asf MCL 13r k.d tlr 4epo.aY ftrh.fe.lPr•ta°' f m.f9 1n3N N.d/.e
P.Il.r.b.rr.Mentl..fd..d dn brr a.grop ROItK ORDER rJ.Y.f atN.N.d l.tlimt..t I.bda.b.d tbt.
.rayrr•t�r w.a r.tA pm.hw Y
abt�m�',/.gaf�n/Jq�6..tf'.n�jw�N�.d[�^.tN 0�1t1t4e.f labapaos.f ta.1HAM e..v.tl.rf�+t�
I d.itrebl le f A H^//'^ e �fMla7 tAaf tie infertwmbe prsvJled abero it tree anJ cwreaY I —
y A/ 'u� — Deb
Print C5, C, k'\ A Phma#
.ifibl me self d.e.1 writbtbY.ro bhrmPl.ted bf.Ifr sr fnrv.rtMW
pe�e.s a �H.Ildbq D.pnbevt
dry or bw.: Qi.Merier Brrd
(]9elatmee'f Oafee
❑�he.i es®.aMM rnPoe..M nywr.a ❑nrMh a.P.,�.ef
yn.se m, Ooth.r
conb.r pens.:
-� The Commonwealth of Massachusetts
Department of Industrial Accidents
-. — Aftrafaffitaiiiii
=_
- - _ 600 Washington Street
Boston,Maser OZITT
Workers Cam station Insurance Affidavit-General Businesses
O V415
name:
KL s Y
.admss: Pv.�h X
nr R w 7v P 1` a , v� A— 1
work 'ter tota,i Rettil❑Ristauran✓Bar/Eating Fsu6lishmmt
❑ I am a mle pmpnetm and have no one Batineas Type:
Office❑ Sales(including Real Fstate,Autos ac.)
worldag in any rapacttY
I am as em l with m to (full & art time . Other
wmkas' com satiim for mY emPloYees wor tm this job.
I am an tsnPloyv]sov,tlmg .� n . A J v v vw
I V Ft r'vr
nemet _ /L
VN
tTP 1�
l X
mmYeoee ea venters'
I am a Ole Pmpnetor and leave hued the independent costrac[tss listed below who Gave the foBovrisB
coml>easation polices:
ro n n.me-
.aare
insuremee eo.
tom n ve
add err
hone X:At". 1 N
ivamrevee ro. e .ave W b si'sod.B eoihr
aped order Satbv ZSA of MGL lt2 no Ird b tb impo.itbv of ettmimt p.a.ta•+
F.Wremrem.prene.r rM _ _
emy..r.'bpr4e°m.^trrw.rdd b�tb 0/Dre etimranr.tMm ettb DfA for rev t•ror�tkm«•�)��t ors luoaenbodt t.
np).fthbabtmretm.r
¢serf• of nJ.,that the inforwaaon pr.olded abort is hus d orreai
I de hereby ceaify render the • 0 Ihae
Signahve C-In kA ' Pliona X -I
Print name
efnehl me Duly ds net wrib b this arm to b completed hY elry or town oa,ebl (]nuadbe Dep.rtmevt
peroJXbeme v (]Lieemive Bmrr
city or W.: QSekstmro'a0 n
cheek tf n dbm rrpomen req�ed Dep.rtmeM
(]Otbr
phone X;
eonbet peso.:
(mveee Sept N111 .���
Note: Complete top of farm and forward both sections and fee to local licensing
authority (City or Town Clerk). Do not make application to department of Public Safety.
�Grimintc�r�ctla_a�Cli ri���Caaaac�2urteG��t
g �eft2rGirtenCe?Sire F7r�uecel — �vuexrm o�'��'rixo ✓�u�ue�ztien
ti
C:ty or—,own NORTH ANDOVER Date
APPLICATION FOR CERTIFICATE OF REGISTRATION
In accordance with the provisions of Chanter tab. Section 13, of the General Laws. the undersigned hereby certifies that
NORTH ANDOVER GUTTY
785 TURNPIKE STREET
is the holder of license granted 2/3/73 . far the lawful use of the buildingfs) or other structures) situated or
oe e
to be situated at 785 TURNPIKE STREET
su..r..o.una.
as related to the KEEPING, STORAGE, MANUFACTURE OF SAL OF PiAMMABLES OF EXPLOSNES.
NORTH ANDOVER, MA 01845
Note: This application for care irare of reg'smerlon must be sinned by the holder of fhe license if said license was
granted pncr ro July 1, 1936, otherwise by the owner or =cant of the land licensed.
Received Submitted by
by
—_-------------------------------------------_
,� � ��rrcc�racuea��i G�. ��kSCLCS
5.®3ry
3`, eJi2rGirzaaCa .J'urte;/ere�ecea — nezx� a r
Ca or Town NORTH ANDOVER Date
REGISTRATION
Thus is to certify that NORTH ANDOVER GETT'Y
has, in accordance with the i isions of Chanter 148, Section 13, of the General Laws, filed with me a certificate of registration setting
forth that NORTH ANDOVER CETTY is the balder at the license granted
2/3/73 for the lawful use of the building(s) or other stnictureb) situates or
an.
tobesitualedat 785 TURNPIKE STREET, NORTH ANDOVER, MA 01845
as related to the KEEPING, STORAGE. MANUFACTURE CF SALE OF F.AMMAELES OF EXPLCSIVES.
Note:A cemfirare of re'srdnan mus:c.fiten on or over,Anni Me dl..c year.
TriIS REGISTPATICN MUST BE CCNSPIOUCUSLY PCSTED ON T?1E PREMISES
iremsed]N6)