HomeMy WebLinkAboutRohm and Haas Company ,5� .��C VrL� CQ'IINYLOyIAL�Y-eLVNL Vry ✓/l.(rfl(NLN(.NRfZ1A.
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'i. Department of Fire Services
3ese �. Office of the State Fire Marshal
P.0.Box 1025, State Road,Stow,MA DI 775
CERTIFICATE OF REGISTRATION
North Andover April 30, 2016
(Co)-,rown) (pat)
NOTE:Complete top and bottom of form and forward both sections and fee to local Licensing Authority(City or Town Clerk)_
DO NOT RETCRN 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): Rohm and Haas Company
(ADDRESS): 60 Willow Street
is the holder of the license granted(Date): 6/20/2001 for the lawful use of the building(s)or other
Amended 06/22/2010 to Store Class I, 115,000 Gallons Pyrophoric and Mixed Solvents Flammable Liquids and 1000 LBS
Flammable Solids.
structure(s)situated or to he situated at (ADDRESS) 60 Willow Street
NORTH ANDOVER,MA 01845
(Cityoriowa)
as related to the KEEPING, STORAGE,MANUFACTURE OR SALE OF FLAMMABLF.S OR EXPLOSIVES.
NOTE: This certificate of registration must be signed by the holder ofthe license ifWd license was granted prior to July 1,1936,
Otherwise by the owner or occupant of the land liecnsed.
Rec ' c ..02.(!'..2016......._
is an )
BY .. ..............L!h�.Cl. .-.................
(O1Tcial Title) (clerk) (Aelcwhnber owne
q occupant or holder)
(Address)
The Connilmpvealth ofMorc,c],uselts
Department ofIndusD'ial Accidents
Office of Investigations
600 Washington SDecteet
Boston,MA 02111
wtviRemarsgov/dla
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information 11 aso Print Legibly
Business/Organization Name: Lf C
Address LL /tiri�-LC'r✓ IifE[=7 -
City/State/Zip: 1) �Phone
Are you an employer?Check the appropriate box: Business Type(required):
1.P I am a employer with 111 employees(full and/ 5 U Retail
or port-ti6. []Restaurant/Bar/Eating Establishment
2,0
me)."1 am a sole proprietor or partnership and nave no
employees working for me in any capacity. 7. ElOft7ce and/or Sales(incl.mal estate,cute,etc.)
INO workers' comp,insurance requirad] 8, ❑Non-profit
3.[] We are a corporation and its officers have use, 9, ❑Entertainment
their right of exemption per e, 152,§1(4),and we have
no cm 10 ees ID.�Manufacturing
p y [No workws'comp, insurancerequired]'
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees,[No workers'comp, insureace req.] 12.❑Other _._
'Any eppllcent IM1xI cnmks box p l meal else fill-111-111 section Will,showing their workers'compcooed..policy lufoemclion
^If llm euryon
argd ahsl,s have exemyl l lM1emselvee,hvl lh=Wepoen:ion hm otlar employees,s worker.?compmsntien policy is mquirctl enC such nn
mieatlon shoul1-d check box pl.
Illinois employer that Is providing workers'compe'ns�a�tla�n"ins�ur�nreee for my employees. Before!s Ibe policy Informuaau,
Insurance Company Name /y[�L , 'pZ/'�'S I//'Q/✓/%
Insl:rcr's Addre s: ;/ l %f ) ipu �J
City/Statt0l, Al( I /LC f 7
'Policy q or Serf-ins.Lie.# Expiration Date: 1�'
Ativuh it copy of the Workers'compensation policy declaration page(showing the policy number and expi,ition date),.
i ilufe to secure coverage as required under Section 25A of MOI.o, 152 can lead to the imposition oforimiml penalties of¢
five up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and¢fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oct._of
Investigations ofthe DIA for insurance coverage ve'fceC i
7 do hereby certify,under d�pniu rrrdpenu(hes of per/wry Ibnl lGe injormmmn pravrded above is true and correct.
Si atue CI , � 7 Date
k , 'i-�� -✓pie
LL.
only. Do rmt nnIte la this area,to be conrphred by cap or lorvu official
n: Permit/License#
hority(circle one):
Hea 7th 2.Building Department 3.City/1'own Clerk 4. Licensing Board 5.Selectmen's Office
..son: Phone#:
wwwm. vs.gov/die