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140 PRESCOTT STREET -PRESCOTT HOUSE
�E�S��.�',S/Ci L/ !� 'L�//1"i%/Gl%IiGG��/T/'�/� - c//,.��/-!i��✓��.1/ 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 30,2020 (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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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, Otherwisee7 by the owner or occupant of the land licensed. 1 Receive Y .2020......... '�B (Signature) ,M (Offici i e (Clerk)... ...................................................... (State whether owner,occupant or holder) t, s G (Address) v' 3 Department of Fire Services Office of the State Fire Marshall as� ��n4 P.O.Box 1025,State Road,Stow,MA 01775 REGISTRATION North Andover, April 30, 2020 (City or Town) (Date) This is to certify that Prescott House has, in accordance with the provisions of Chapter 148, Section 13, of the General Laws, filed with me a certificate of registration setting forth that: Prescott House is the holder of the license granted(Date)9/17/1981 i for the lawful use of the building(s)or other structure(s)situated or to be situated at: 140 Prescott Street as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. .............. .�.y2 (Signature an fficial Title) Clerk Note:A certificate of registration must be filed on or before April 30'h of each year. (THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.) EXPIRES APRIL 30,2021 E, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please.Print Legibly Business/Organization Name: ya w— t ou-0 --czl . Address: /YO7f s i city/State/Zip: K -V Phone Are yo an employer?Check the appropriate box: Business Type(required): 1, 'lama employer with /e!O employees(full anal/ 5• ;Retail or part-time).* 6, Fj Restaurant/Bar/Eating;Establishment 2,❑ 1 am a sole proprietor or partnership and have no ?, []Office and/or Sales(incl,real estate,auto,etc.) employees working for me in any capacity. •8. ❑Non-profit [No workers' camp.insurance required] 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.❑M ufaeturing no employees.[No workers'comp,insurance required]* 11.[ Ith Cam Q,[] We sre a non-profit organization,staffed by volunteers, 12.❑Other with no employees.[No workers'comp,insurance req,] «Any applicant that Checks box it I mug also fill out the section below showing their workers'eomper>sation policy Information- *Any the corporate offiaers have exanpted themselves,but the corporation has other employees,a workers'oompensatioa policy is required and such an orgmization should check box#]. I am an employer that is provift workers'compensation insurance jar my etwloyees.. Below is the policy informutlon. Insurance Company Name: Insurer's Address: l /�/w we,,wL C ev t L_ �6 s City/slat aip: J- s ti e i,5 Policy#or Self-ins,Lids# C)i y G Y ° ' Expiration Date: i� r/7 a Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).• Failure to secure coverage ss required under Section 25A of MOL e, 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year briprisonment,as well as civil penalties in the form of STOP WORK.ORDER and a fine of up to$250,00 a day against the violator. Be a&ised thata copy of thin?stater:ern may be forwarded to the Office of Invcsti orts of the DIA for insurattoe coverage verification, I I do hereby cert{J3►,under the pain and penalties ofperjury that the information provided above is true and correct i ature; �' n77 O,ffloial use only. Do not write to this area,to be completed by city or town ojj`Iciat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4,Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.govtdln I Acow p® CERTIFICATE OF LIABILITY DATE(MM/DD/YYYY) INSURANCE 06/03/2019 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: 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 [Boston, ertificate holder In lieu of such endorsement(s). DUCER 1-617-531-6000 CONTACT tegro USA Inc. NAME: Integro Insurance Brokers PHONE FAX Financial Center C N t, ac No): E-MAIL South Street, Suite 800 ADDRESS: MA 02111 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hudson Excess Insurance Company 14484 Genesis Healthcare, Inc. INSURER LIBERTY MUT FIRE INS CO 23035 101 East State Street INSURER C: NEW HAMPSHIRE INS CO 23841 INSURERD: AMERICAN HOME ASSUR CO 19380 Kennett Square, PA 19348 INSURERE: COVERAGES INSURER F CERTIFICATE NUMBER: 56329915 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 MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS IT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE WOW UBR POLICY NUMBER POLICY EFF POLICY EXP A GENERAL LIABILITY MM/DD MM/DD/YYYY LIMITS HFF100067-1803 12/01/1 12/01/19 X EACH OCCURRENCE $ 3,000,000 COMMERCIAL GENERAL LIABILITY DAMA E T R NTED 3,000,000 X PREMISES Ea occurrence $ CLAIMS-MADE 7OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 TPOLICY PRO- PRODUCTS-COMP/OP AGG $ 3,000,000 B AUTOMOBILE LIABILITY AS2-631-004097-348 $ COMBINED SINGLE LIMIT X ANY AUTO Ea accident 1,000,000 ALL OWNED BODILY INJURY(Per person) $ AUTOS SCHEDULED AUTOS BODILY INJURY Per accident $ X HIRED AUTOS X NON-OWNED ( ) AUTOS PROPERTY DAMAGE $ Per wident UMBRELLA LIAR $ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE DE AGGREGATE $ D RETENTION$ C WORKERS COMPENSATION WC 014649238 WCSTATU- OTH- $ AND EMPLOYERS'LIABILITY 0610111 11/01/19 X C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 014649240 06/Ol/1 11/Ol/19 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ 1,000,000 C (fyes,dory In NH)beund WC 014649236 06/01/1 11/01/19 D If yes,describe under E.L.DISEASE-EA EMPLOYE $ 1,000,000 DESCRIPTIONOFOPERATIONSbelow WC 019649239 06/01/1 11/Ol/19 E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Medical Professional Liab HFF100067-1803 12/01/1 12/Ol/19 Each Med. Incident 3,000,000 (Retro Date: Various) *Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) } *GL and MPL Policy subject a combined $3,000,000 policy aggregate and is inclusive of the applicable policy deductible. Additional WC Policy: WC 014649237 The Named Insured is Self Insured for auto physical damages. Evidence of Insurance CERTIFICATE HOLDER CANCELLATION 140 Prescott Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Operations LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN } d/b/a Prescott House ACCORDANCE WITH THE POLICY PROVISIONS. 140 Prescott Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 USA ` ©1988-2010 ACORD CORPORATION. All rights reserved: ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Anne.Chang@integrogroup.com BOIS 56329915 x i p 1 Department of Fire Services Office of the State Fire Marshal ` p O.Box 1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION • 30 2019 North Andover April(Date) (City or Town) orm and forward both sections and fee to local Licensing Authority(City or Town Clerk). S. NOTE:Complete top and bottom of f DO NOT RETURN FORM TO THE DEPARTMENT OF FIRE SERVIC In accordance with the provisions of Chapter 148,Section 13, of the General Laws,the undersigned hereby certifies that: (TITLE HOLDER): Prescott House 140 Prescott Street s or other (ADDRESS) for the lawful use of the building(s)) is the holder of the license granted(Date): 9/17/1981 at ADDRESS): 140 Prescott Street structure(s) situated or to be situated NORTH ANDOVER,MA 01845 (city or Town) BLES OR EXPLOSIVES. NUFACTURE OR SALE OF FLAMMA prior to duly 1,1936, KEEPING, STORAGE,MA the holder of the license if said license w 01 as granted as related to the KE ' NOTE: This certificate of registration cumustbe of the and licensed. Otherwise by the owner or occupant (Signature) '. .2019......... ................... VB V(�o� al ......................... or holder) (State whether owner,occupant (Clerk) ...........................................(Addr .) ' (Addre�cl The ConownWCaUft o,�`Mcrssr�clausetts Dgwtment of IndustriatAccidettlts owe o,f Xnvestigatdvns 604 Washington Strctt Bostoitr 02111 rnas�govldio Workers, Comp insurlartee,Affida'vit Ge�eraI Businesses PXease Prat Le ' t A Iicttnf Informatlhn usinesOrganzation Name: ; Address. s MY/StatelZip; tiate.Iio7c: Bushms Type:(requ�; Are you an emp1 "?Cliaak tfie aPprnP 5. C3 Retail i;Fyrl am a=ployer wit-_e,npioye:s Ofall andl 6, []RastaurantlBar/gating Establishment or park tirrtn).* • arshi and have no 7• Office and/or Sales(inci real estate,auto,etc.) 2 0 1 am s sole propnetut 4k psrtit p p employees working for me In any capacity •g; F]Nan-profit [No worker!cntq.:�tt n '�d7 sod 9, 0�inment 3•❑ We am a corporation and its ovoe"have-extra No workers of exam k to . ,$l(4),and we have 14.[_])Yfa�tnfacturirtg their right Pit° c 152 � � mo employees; oomp•instccattca rtgtair4 I I„0 Health Care q,❑ Vile are a non.PM t.cngant� staffed by vofuntesrs. 12.Uj( her vyorkcrs oorrap,m;3uraneatecl•] tzdarnrszn. With no ernpl'egees, ° nrcat Work«e'aompenaation policy s 'p Tcki'Tthat choc S t mast slid fill but t section tw1ot�ahov B. ros a v n&rksn'astmpGnseti�policy is nyvired and such sn �nsefves,brit-the catparaton!>aa '��" ° ft.WTpOTAta01�t'�Y8}SSYG�Xdtij>�d ' n;zatlonshoo ld.etuolcbox#1. ( ees:. Bdlow�is the of cy I4fvrmaftJL la er tlu+dr larortdtn8.s+or.hers'cOMperrsattan tnr;rerarlea far►iq' P�' r it*mom y Insurance ComP 'N Insurer's Addresss "T ` �'/ CtylSlscl�ip; S i .v ' E=JrWon Date policy Cor Self-ins.Lta.. cv.G � �hovving the,.policy5lombe�qiratiou a}: 3 ran policy declaration page Attach a copy of the Workers cc►mpeA Failure to se t a aa" g°''as regaired under Se�otlon25A of 1s'OL c,152 can lead to the impasifion of ORK crjmiinai p ORDER and a fine as will as-civil panawes in tie fonla f for op.,,W. � ce a fine up to'S1,544:4t1 atuEa;+ne`�' r' riavPrtten#, this s� y i of up to$ZS4 40'a is aSa ate viDlatQi 8e advised that a copy i „ a� upftheXA forIsn1Yll e verifrcation; 111q hereby COO, under iltdp trrtdpe rt#tet of peu 'fhre the 1ipformaOx Provided rtbyv� s at?d rrrec� L_ e• '� & by Chy or twit p ffiatu( ably. Do not write-in Mu.area,to be cart& Perr»t111•+icense# city or Town.l liming Authat ity(circle ouej: L Board of Health 2.Building Department 3.Cityrrowu Clerk �.1,}censingEoard S,Seiectet+en�s Office i t other phone fk Contact Person; yrrasss,gsYlttin I . � I DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE U5/01/zo18 �--� E HOLDER. ACORL7® `..� AND CONFERS NO THIS CERTIFICATE I N ISSUEOT A D AS A IRMAT VELYEOR NEGAT VELYR OF I AMENDON YEXTEND OR AL ER TIHE COVERAGE AFFORDED BYTHE POLICIES CERTIFICATE DOES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSe RED�an endo the lrse(mentn A statement on this certiust be li Dised. ficate does aoOs not aonferDightsfto the the terms and conditions of the policy, certain policies may require certificate holder in lieu of such endorsement(s). CONTACT 1-617-531-6000 NAME: FAX PRODUCER Integro USA Inc. PHC.ONE AIC : No dba Integro Insurance Brokers E-MAIL Two Financial Center ADDRESS: NAIC# 60 South Street, Suite 800 INSURERS AFFORDING COVERAGE Boston, MA 02111 INSURER A NEW HAMPSHIRE INS CO 194445 INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 94 INSURED Genesis Healthcare, Inc. INSURERC: INSURER D 101 East State Street INSURER E Kennett Square, PA 19348 INSURERF: COVERAGES CERTIFICATE NUMBER: 52754835 REVISION NUMBER: LISTED BELO HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POICY PERIO THISS TO CERTWITT AT THE LICIESQOF IN UIREMENNCE TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOL LWHICH THS IND OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM CERTIFICATE MAY ISSUED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RE oucYD BY P Po I YAEXPS LIMITS ADDL SUBR POLICY NUMBER MM/DD MMIDD LTR /YYYY SR TYPE OF INSURANCE EACH OCCURRENCE $ GENERAL LIABILITY DA AG T EN ED $ PREMISES Ea occurrence COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) $ CLAIMS-MADE D OCCUR PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ GENT AGGREGATE LIMIT APPLIES PER: $ PRO- LOC COMBINED SINGLE LIMIT POLICY T 71 Ea accident AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED PROPERTY DAMAGE $ AUTOS AUTOS NON-OWNED Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR $ AGGREGATE EXCESS LIAR CLAIMS-MADE $ DIED RETENTION$ 11/01/18 X WCSTATU- OTH- A WORKERS COMPENSATION WC063724356 05/01/1 $ 1,000,000 Y AND EMPLOYERS'LIABILITY WC063724353 05/01/1 11/01/18 E.L.EACH ACCIDENT A ANY PROPRIETOR/PARTNER/EXECUTIVE❑ OS/O1/1 NIA OFFICER/MEMBEREXCLUDED7 WC063724354 11/O1/18 E.L.DISEASE-EA EMPLOYE $ 1,000,000 B (Mandatory in NH) 11/O1/18 1,000,000 If yes,describeunder WC063724355 05/01/1 E.L.DISEASE-POLICY LIMIT $ A DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Policies: WC63724357, WC63724358, WC63724359, WC63724360, WC63724361, WC63724362 RE: Genesis HealthCare and its subsidiaries. Prescott House 140 Prescott Street, North Andover, MA 01845 CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FNorth House ACCORDANCE WITH THE POLICY PROVISIONS. ott Street AUTHORIZEDREPRESENTATNE � dover, MA 01845 USA i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD com BOS Anne.Chang@integrogroup. ..cV•;y. �?,Pi L�I�JI?/J�21Y122Gk�e22%/l"7� c���G �Z./CG�'�� Department of Fire Services Office of the State Fire Marshal P.O.Box 1025,State Road,Stow,MA 01775 t xi CERTIFICATE OF REGISTRATION E North Andover April 30, 2018 (City or Town) (Date) j 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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. ................................... �...72018......... ...... Received •• (signature) By �(Officig *' Clerk .(State whether owner,occupant or holder) (Clerk) .............................................. (Address) ;V Department of Fire Services tyJ� Office of the State Fire Marshall P.O.Box 1025,State Road,Stow,MA 01775 s�� 1 REGISTRATION North Andover, April 30, 2018 (City or Town) (Date) This is to certify that Prescott House has, in accordance with the provisions of Chapter 148, Section 13,of the General Laws,filed with me a certificate of registration setting forth that: Prescott House is the holder of the license granted(Date)9/17/1981 Street for the lawful use of the building(s)or other structure(s)situOateTUoRr tEo be situated at:OR SALE OF F 140 PrescottABLES OR EXPLOSIVES. as related to the KEEPING, STORAGE, MANUFA (Signature and Official Title) Clerk Note:A certificate of registration must be filed on or before April 30'of each year. (THIS REGISTRATION MUST BE APRIL 30,CONSPICUOUSLY POSTED ON THE PREMISES.) EXPIRES r • k The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 I www.mass.gov/dta Workers' Compensation Insurance Affidavit: General Businesses Please Print Le ibl A licant Information Business/Organization Name: Ala r I•V _ � Address: / �r t s c !� r r w- City/State/Zip: oo 0 r v Y Phone Business Type(required); Are yo an employer?Chet:k the appropriate box: 5 Retail I am a employer with y, employees(full and/ 6, ❑Restaurant/Bar/Eating Establishment or part-time):* 2,❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales(incl.teal estate,auto,etc.) employees working for me in any capacity, •g, Non-profit [No workers' comp,insurance required] 9. Entertainment 3,❑ We are a corporation and its officers have exercised 10 ❑Manufacturing their right of exemption per c, 152,§1(4),and we have no employees,[No workers'comp. insurance required]* 11.❑Health Care 4,[] We are a non-profit organization,staffed by Vol unteeq) 12[]Other 1 with no employees,[No workers' comp,insurance re , *Any applicant that chocks box#1 must also fill out the section below showing their workers'compensation policy inibrmation, **If the corporate officers have exempted themselves,but the corporation has other employees;a workers'compensation policy is required and such an organisation should cheok box#1. I am an employer that is providing workers'compensation insurance for my employees. .$elow is the policy information, Insurance_Company Name: S H Insurer's Address: / CitylStatelZip; • Ex iration Date: Policy#or Self-ins,Li,,.# d� �--�y - p of the compensation policy declaration page(showing the policy number and expiration date).- Attach acopy lead to imposition of criminal penalties of a I Failure to secure coverage as required iunde radio,s A ofll as c L penalties in the forme of a STOP WORK OTtDER and fine fine up to 50,00a d and/or one-year p of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwai•ded.to the Office of II Investigations of the DIA for insurance coverage verification. I do liere6y certify,under the pain and penalties of perjury that the information provkled above is true and correct Date- Si nature' ,i Phone Official use only. Do not wrlle In this area,to be completed by city or town official, I Permit/License# City or Town; Issuing Authority(circle one): epstrtment 3,City/Town Cleric 4,Licensing Board r5,Selectmen's Office I,Board of Health Z.Building A I 6.Other t Phone#t Contact Person: - - www.mass.gov/die TOWN OF NORTH ANDOVER OFFICE OF TOWN CLERK 120 MAIN STREET NORTH ANDOVER, MASSAC14USETTS 01845 NORTH Joyce A.Bradshaw c� °� Telephone(978)688-9501 Town Clerk " FAX(978)688-9557 b ,Ar.o SA US E-mail: ibradshaw(a)townofnorthandover.com 2018 Renewal To All above Ground and Underground Storage Tank License Holders: Enclosed please find your Registration Renewal Form(s) for above ground and/or underground storage tanks. Renewals are due April 30til of each year. The fee for renewal is $150 per site. the iate Please sign the top portion of the registration 20 Main Street North Andover and return it thMA Op845prThefee, payable to the Town of North Andover, 1 bottom portion is yours to be displayed along with your license. Also included is the requirement to provide an affidavit showing proof of Workman's Compensation Insurance. Please fill out and return the form to us with your renewal. Your immediate attention in this matter is greatly appreciated. Thank you for your continued cooperation. Please do not hesitate to contact me at the above listed phone number if you have any questions or need additional assistance. Very truly, Joyce Bradshaw Town Clerk Enc. , t E ~ - TOWN OF NORTH ANDOVER OFFICE OF THE TOWN CLERK 120 MAIN STREET NORTH ANDOVER,MASSACHUSETTS 01845 s Telephone(978)688-9501 Joyce A.Bradshaw,CMMC Fax (978)688-9556 Town Clerk NORT1{ F t ,'SSACHUSEt E-mail ibradshaw(a-townofnorthandovencom TO: All License Holders—Proof of Workers' Compensation 2018 Included in the renewal package renewal18 of ls the attached form which must be the Underground Storage Tank completed and returned with your Certificate of Registration. Massachusetts General Law Chapter 152 Section 25A requires that all employers conducting business in the Commonwealth of Massachusetts must carry a valid workers' compensation policy at all times. Proof of this coverage will be verified with the insurance carrier directly or the Department of Industrial Accidents (DIA), Office of Insurance at 800-323-3249. The Office of the Town Clerk will retain a copy of the enclosed Workers' Compensation Affidavit. If you have any changes in your insurance carrier or have any questions please contact our office at(978)688-9501. Please return the completed form with your license renewal to Town Clerk's Office, 120 Main Street, North Andover, MA 01845. We appreciate your assistance and cooperation. Sincerely, Joyce A. Bradshaw, Town Clerk t �r •G, 4 Department of Fire Services yJti yi Office of the State Fire Marshal P.O.Box 1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION North Andover April 30,2017 (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): Prescott House (ADDRESS): 140 Prescott Street for the lawful use of the building(s) or other is the holder of the license granted(Date): 9/17/1981 escott structure(s) situated or to be situated at NOR(ADDS): 140 Pr 01845 Street (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. . .. ..... .. R eiv ..2017......... (Signature) $ '•''• (State whether owner,occupant or holder) (Official Title) ( I rk) .......................................... (Address) i 's The Coomal tvealtA: a,f'Massachusetts i Department of Industrial.Accidents [ I Office,of Avestigrat ons � 600 Washingfort Street Boston,MA02111' wtvw.mass govlttia Worlters' Compensation Insurance Affidavft: Genera .Businesses Applicant Inforinnfio i Please Print Legibly Business/O.rganization Name: u ' Address: /0ri.s e"dly� i city/State/zip m _SUS Phone# ' ri 72-/off 5-kdF�o .Are you an employer?Ch6elt the appropriate box.::: Business Type{ cqd ed). IVI am a empl"aysr with /.55 employees(fttll and/ 5. El Retail or part-time):* 6, [] Restaurant/Bar/Baying Establishment: I❑ .I am a sole proprietor or pamership and have no ?, (]Office and/or Sales(incl:reel estate,auto,etc employees working for me in any capacity: (No workers''comp,insumnoe required] 8: []Non:profit 1 E) We are a corporation and its oftioers have exerzised 9; []Entertainment their right of exemption per e. 152,§1(4);and we}nave: 10.[]Manufacturing no_employees:[No workers'comp insurance requlrod]* 11.[]Health Caro 4:n We area nonprofit organization,,staffed by volunteers, with no employees.[No workers''comp,insuranee req.] 12,Q Other. *4py:apprimif that checks bo0 I must also fill otit.the seetibn boloµ*oWing their workers'oompensation policy information, **lf tho eorporete officers Have exampttid themselves;but the eorporatlon lim other emptoyoes;e.workeri'oompensntion pokey is required:acid such nn orgadi�tion should ohook b9x ff) loth."employer that is providlitg►corkers'comptim.06n insurance for my employed..Odow•.ls the,poliey lnfortluiilon. Insurance:Company Name; �y-i,rd Snokt, lnsttrer's Addre= ho 1) / aL -- City/state/Zip., tl r !-� C,fi �3n.31 y Policy. #or Self-ins,L,i.c:# `J /r (4,�,40 y Expiration Dater_ ---- Attach a:copy of the worlters'comhensatian nalicytleclaration.pa.ge(sherving the policy number and expiratibn'date).. Failure to secure coverage:as required under.5eotion 25A of MGL.c,IS2.can lead to the imposition of criminal penalties of a .nine up to.,$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forrn of a STOP WOE ORDER and a fine of up w$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 D1A for insurance ooyerage verifeatim. I dahereby cerilfy,ursrier the cuts scl naltim of perjury that:the infor'madon provieka above is true will sourest S' citricit 0, Date:. phone#•- Offlo4 at only. Do parr iPrite n th1s:area,to rie 0an!Pkted 6,y city or lotpn official. City or Town: Permit/I,icense Issuing Authority(circle one): LOOtber .of Health 2.Building Department 3,City/Town Cleric 4;Licensing Board 5.Selectmen's Office Person; Phone www:mass:gavfdia s U4ie Cintn22rL e4GLfa � �dac Fl��� �y Department of Fire Services Office of the State Fire Marshal I'.O. [lox 1025.Staw Ruad.Stow_VIA 0I775 CERTIFICATE OF REGISTRATION North Andorcr April30, 2016 (Ciy, IDmN (Dnbl NOTE: Complete top and houum of form and fotwurd both...l ons and fee to local I.icens'mg Authuntc(("I or Iocn Clerk I. DO NOT RETURN FORM TO THE DEPARTMENT OF FIRE SERVICES In accordance with the provisions ofChapter 148, Section 13, ufthe General Laws,the undersigned hereby certifies that. (TITLE HOLDER): Prescott House (ADDRESS): 140 Presmu Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the buildings) or other structure(s) situated or to be situated at (ADDRESS): 140 Prescott Street NORTHH ANDOVER, MA 01945 furyorrm,nl as related to the KEEPING. S"FORAGE, MANU17AC LURE OR SALE OF FLAMMARLES OR EXPLOSIVES_ No ,E: Phis certificate of registration must be signed by the holder of the license fluid license was granted prior to Iuly 1.1936, Otherwise by the owner or occupant of the land licensed. ��N 1 2016 HR 6ignnt rc1 . ............ ( finial Titlo 'lerq (Aaha nhcthermrncr_rccupnnt ov holden ...................................................... The Commonwealth OfMassacliasetts Department of lndustrialAccidents Office oflnvesHgtafons I 600 Washington Street Boston,MA 02111 Workers' Comp www.massgov/dia Applicant Information ensation Insurance Affidavit: General Businesses Business/Organization Name: Please Print Le •bl I n -t Address: APe•city/state/zip: Cn I Phone#: Are yy{t an employer?Cheek the a %�b -f` � � -3'Ch( 1 f am a employer with ppropriate box: Business Type(required): or part-time), • (z{ employees(full and/ 5. QRetail 2.0 1 am a sole proprietor or Partnership and have no employees workin for me in �' Restaurant/Bar/Eating Establishment g arty capacity p Ty. ❑Office and/or Sales(ind.real estate auto,etc.) [No workers'comp.insurance S. 3. We are a corporation and its officers have exercised Non-pmfit therrightofexemption per e. 752, 74 and we have 9. Entertainment no employees, § O' ]0 [No workers'comp, insurance requbed]• nufacturing 4. We are a non-profit organization,staffed by volunteers, I I• earth Care with no employees.[No workers'coin . •Anr eppliranRhat the P mswence req,] 12,Q Other s lfNem cics baxMl mustelse(Jl out Ne section below showing @eirworkers' o mmak offices have cumpktl Nemselves, on win «satien li N'ormnion. rganv&ioo shoWd check bvxpl, but Ne coryorae has Dour P m" compensation oii I aln an a nialo er 1h P nY v inquired msd such en i proy ding orkers compensation msuran Insurance Company Name. - _ j011tr1' mp[oyees. BeWw IS arepoluy rnjormadon. Inswer's Address: ' '- i, i City/Sate2rp: r t /, i ('r �. Policy#or Self-his.Lie:# Attach a copy of the workers'compensation Policy Expiration Date: on Failure to secure coverage o required under Sechbn 25A¢of MGL c. 152 can lead to the imposition Of criminal penalties of a Page(showing the olic number and expiration date).. fine up t$ 50.001 d and/or st th r imprisonment as well as civ`I penslties in the form of a STOP WORK O Of up m$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office a Investigations of the DlA for' ORDER and afine I uumaoce coverage verification. I do hereby certify,under he pabui penalties o er' IP !a y llsat die injorma ion provided above s traa and corr¢ct. Si ature: _ti �' =Othcr only. Do not IPrae ht this area,to be completed by city or tower official n: — ori Permif/I,icense# calth(2,Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office on: Phoae#: www.man.gw/dfe A A�5\5'm�.sl�f V{1.E l.6IYN/4lNV✓✓.P.G�LLfl � ✓/enNtVMGiL4fdPirA.U- e .JJ/ Department of Fire Services Office of the State Fire Marshal 4 \ P.O.Be. 1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION North Andover April 30, 2014 (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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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 ofthe license ifsaid license was granted prior to July 1,1936, OtheerwIsa by the owner or occupant of the land licensed. 'p Received ... . 'he. .... !/bZZ2014..... .. ...... ... ... .....xl-:4 14............. ..... ignatum) By ....... 'AAM.f .. ........... ........................I............. cial Title (Clerk) (State whether owner,occupant or holder) (A ddress) (Adddress) The Commonwealth gfMasswhusetis Department oflndicstrialAceidents Offtee of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly . Bminess/Organization Name: /i rscezT 1Seew5e �Uur'sr.u,o eTR . Address: /t/6 4tfco17- Si,eeT C]TylSlate/Zip: o a('✓ro Jed-, 6/91` Phone#: An an employer?Check the appropriate box: Business Type(required): 1.[� I am a omployer wiN /9G employees(full and/ 5. ❑Ransil or Part-time),• 6. ❑RestauretNBar/Eating Establishment 2.❑ 1 Intl a sole proprietor or partnership and have rm ? ❑Office sandier Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g, ❑Non-profit [No workers'comp.inemance required] 3.❑ We are a corporation and its ofCroers have exercised 9. ❑Entertainment then right of exemption per c. 152,§l(4),and we have 10.❑,_,/xManufacnaing no employees. [No workers'comp.insurance requir I 1 eehh Care 4.❑ We am a non-profit organization,staffed by volun 11 Er +� with no employees.[No workers' comp.insurance raq.] 1 12.❑Other *AU applisen this cheeks box#]mM also fdl at the a:etim belowrhovag taekworken'ownprmsatim polity isdormnion. arlfthemwmmotfioeshneexempaAaemselrrs,bMt amryomflanhmothu mployeegaworlme'oompe flmpolirynmquimdmdsuohm orgmbaaon should oheok box M. jam an employer that is providing workers'compensation Insurance for my employees. Below is Ill Information. Insurance Company Name: ./ Je i rr CO _ Insurer's Address: /S .(/wo r r. A.0 iA City/Stete/Zip Ad/A Policy#w Self-ins.Lis# rL A > - v 1, - too Yo 97 Expiration Dote: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to mum coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fore up to$1,500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up m$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 verification I do hereby certify,under the pains and enattle's a(pperjury that the information provided above Is true and correct. ""'l— Date Y�QL/q Phone# 9'?F! -'GPS -Po 8(o Off dial use only. Do not write In this area,to be completed by city or town ofjciai City or Town' Permit/Liceme# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Concoct Person: Phone#: www.maw.gavldia • , .••y, nJ{ie Lwrcn�anzeaeC� `9" .�ieoeac�uraeCfa 2 F` S Iy Department of Fire Services Office of the State Fire Marshal "z P.O.Be.1025,State Road,Stow,MA 0t775 CERTIFICATE OF REGISTRATION North Andover April 30,2015 (City at Town) (Date) NOTE:Complete top and bottom ofform 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott Street _ NORTH ANDOVER,MA 01845 (City nTown) as related to the KEEPING, STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. NM: 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 ofthe land licensed. Received ....�Rr'."_.�?/......2015......... ... .......... By ......... l Cf,� ..... ............................... (Official Title) (Clerk) (Sine whether ownrr.occopmt or hold.) ...................................................... (Md.) The Commonwealth ofMassnehusetts Department oflndustrialAccidents . Office oflnvestigations 600 Washington Street Boston,AM 02111 www.massgov/dta !% Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organizmion Name: Yfesen4 ts .se Ah,rs.'TC4r Address: 10 - resezl* S{reef City/State/Zip: ,1/o-" dadj rer M& otfYS Phone#: 44y- GLS.kale L Are.,yyoou an employer?Check the appropriate box: Business Type(required): 1.ua l am a employer with /90 employees(full andl 5. ❑Retail of part-time)." 6, ❑Restaurmn/BerlTating Establishment 2.❑ I an a sole proprietor or partnership and have no 7• ❑Office and/or Sales line].real estate,auto,etc.) employees working for me in any capacity,[No ❑Non-profit [No workers'comp.insurmmrequired] 3.0 We are a corporation and its ofioers have exercised 9. ❑Entertainment their right of exemption Per a 152, §I(4),and we have 10,❑ enufamurin9 no employees. [No wmken'comP•insurance required] 11.ILJHeelth Care 4.❑ We am a non-profit organization,staffed by volunteers, 12.❑Other with no employees.(No wodkers' comp.insurance req.] -AnywplimnreWchecksbm:9i man elm fdl numb;.. belowuwmsgaevw.- -.1- alioapolicyitemedion. t�1flbE NryMkOtrICEr911ECERG11pICd IbENSEiVC9.b@tKCelp]Rnon 110ONW EmpI OyEGi,EM9fk09'[OInPE16WO11 pEI1Ey IE ID�a1Rd tlId 111ChM ' o�im11M sfiould chaok box tll. !amaiemployer Usas Csprovtding workers'compensation insurancefor my employees. Below Isdiepolicy information. - lnsurence Company Name: insurer's Address: /s K%ng5- -,i n 'dr City/stasaip: la CyAl yd OA f900y Policy 9 or5elf--ins.Lie#JdJl{7-/any Q/]fLn-g7 Expiration lMe:ysl,/,S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Pailun to enters coverage as requ red under Section 25A ofMOL c.152 can lend to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisomnent,0 well as civil penalties in the torn of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised Net a copy of this sheamentmay be forwarded to the Office of Investigate ns of the DU for insurance wvemge verificefioa I do hereby certify,corder rh ' a and names eperjury that the Informatlnn provided above is true and correct. Simtaro I.1d' Date Y/4�/t Phenol =Other arty. Do not write m this area,m be completed by elty or town ojl7daC n: Permit/License# ority(circle one): Health Z.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office son: Phone#: - www.mers.govldie w���.»_'rpk V1W lQJ fiN)WlLskt¢aGL/L OL C{IAI.QPiKd. z Department of Fire✓Services Office of the State Fire Marshal P.O.Box 1025,State Road,Stow,MA 01715 CERTIFICATE OF REGISTRATION North Andover April 30,2013 (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. n accordance with the provisions of Chapter 148,Section 13,of the General Laws,the undersigned hereby certifies that: TITLE HOLDER): Prescott House (ADDRESS): 140 Prescott Street s the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other aructure(s)situated or to be situated at (ADDRESS): 140 Prescott Street NORTH ANDOVER, MA 01845 (City or Town) u 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. Receive .. .Q........2'01_1......... .. 1 ................. By .... jyrkffd aj... ...................................................... cid Ti, ) (Clerk) (State whether owner,occapara or holder) .....L.YA..../ln Yd�r.;e .. 7—G P.(7......... (Address) The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washinglon Street Boston,MA 027I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Ix¢ib� Business/OrganizationName: 04 e CcaTT fLe/.fP NWP-4 C7-.P Address:/J� AjtiKetilr Sr A e e i City/State/Zip:Afn, d,{ rk Phone#: 941? - Get-epee, Are y�o an employer?Check the appropriate box: Business Type(required): I.LJ I am a employer with /�employees(full and/ 5. ❑ Retail or part-time)." 6. ❑Restaurant/BanEating Establishment 2.❑ 1 am a sole proprietor or partnership and have no g ❑Office and/or Sales(hi real estate,auto,etc.) employees working for me in any capacity. g, ❑Non-profit {No workers'comp.insurance required] I❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑trlanufacmring no employees. [No workers'comp.insurance required]• I 1 0?rHealth Care 4.❑ We arc a non-profit organiration,staffed by volunteers, 12 ❑Other with no employees. [No workers' comp. insurance req.] 'My appiirsnt that checks box#1 mast also fill pal Ne section mi.showing their workers tom emation policy inforsrwiun. -]f the corporate oAars heve exempted themselves,bra the corporation has olhm employees,a workers cumpmsaaon policy is required and such an u,sonetion should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below 15 the policy information. Insurance Company Name: L�/ f /-taTl,q{� � S;,�i[eej(.G°• llJ, Insurer's Address: t City/statrjzip:— &414 6Z'dZ a, V n F �r/ / 9 o n I/ Policy#or Self-ins.Lie.# " 9 - G ?A - D n y 9 7 -JR7EExpiration Date: 5 r do t 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 of MGL 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 insurance coverage verification. I do hereby certify,under the paim and penalties of perjury that the information provided above is true and correct Signsn Phone# 949 ` G85' -Xat;Y EEOther only. Do not write in rids area,to be completed by city or town ofciaL n: Permit/License# hority(circle one): - Health I Building Department 3.Cityrrown Clerk 4. Licensing Board 5.Selectmen's Office on: Phone#: www mess..../die h5:•m"Yr4; V IW l,o/1zf7zarlsita,a.GLlL {/y ✓/411i14�rf{Q�f.Q Is Department of Fire Services Office of the State Fire Marshal P.O.Be. 1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION North Andover April 30,2011 (City or Town) (Data) 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): Prescon House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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 ifsaid license was granted prior to July 1,1936, /1 otherwise by the owner or occupant of the land licensed. ZA Received .GLjO!�!(..e2 ......2011... G ...... . By ...... . ......... P (acid Tide) (Clerk) (Brute whether owner,occu amwholder) (Address) The Commonwealth of Massachusetts Department Of Industrial Accidents Aft7Lf 600 Washington Street Boston,Mars 02111 Workers' fom enratiaa lnsaraatt.4t6davft-Gene..al Businesses nma' .ddresr 'tv stntrzW -hum g wvsk site IattiSm(full addle 1- ❑ I am a sole propriear and have no one Bnvam'Iype: ❑Retool❑RestaurnaUBor/pating Pstablishmeut working in any capacity- ❑Office LEJ Solm(inclofiag Real Pstatg Ante. ec.) ❑ I am aD® 1 wth em to full & art time . o Other I am >m rmphryc povk ft w kctt'—peatatim far my®ployees aurkmg m this jab. mmn.nr n.ne: �rescotF' Howse �.Ge rras�.s Fla r.:lth �nxe -- C' e.n.Yo ona��-t r�rt .dareaa: b 17 4alls ttv (\)M�k And.f)yer MIS Ol?'tt'�— . .. -boor in.wee rn' Ll o c, JAW.� J c C. Con. dM l -WR7- 103d -0O +C4`l—aSC7 I am a sole p7-ctm and have hired the independent contractors listed below who have the following w kct' compeasaliot policm: romeaev mesa-. .ddre.o: itv^ b p lnrure.,e rn flee a .ddrer: cfttt nb .F in.areoee rn. - P.W:r.b�rcm.w.enK r+�9�Y•d mdn 9atYv'SA NMQ.I53 e.k.d b Ihs lmpudYa N.rbdml pe.ltb N.�.np bt1 jN,N nstbr .a y+.n'mprMm..t r wa r oleo P•a•br Y rb.Yrm N.bTOP RORY ORDER.d•au.ftloa.M•d.r.s.tmt s I o✓w.bY eLt v.pf.f tli abhpe.[mr d frw.tded Y the Ofhe NlmrtlK Ws Ntb DIAIK e.m.a.�IbW� I d.boeby rmtffj.ndn lFrpains and n ale.fparjngtt teinf.rrmi.npr.ridedab~is true"den, Signatme� / Al f//�.�T// I)ebs _� 7�f.20 Ponttsama CSC. �s W A tf7A. 14 Phone 11_ P71 -l.FS-,-e FA MMM ef .Alm edr d.mterlbbtl�Y.ru bMesmpbttl by clry.r Ya7 a1.W edy or bwe: prpaN..r.a (]Romer D.p.r�a ❑tbrk unmedbr rrpvr.�.r.gwr W pl.iee nm e...d O&ket ."Otte enbet pera.e: I]Hvkh tp..M ph..P d.� DOther es-.:sF C�he L4JYU1taTlst¢C7./�GlL OL �d.G.Ch[(dP� <<c J Department of Fire Services Office of the State Fire Marshal R O.Be.1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION North Andover April 30, 2010. (City or Town) (Dart) 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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 ofthe license ifsaid license was granted prior to July 1,1936, Otherwise by the owner or occupant ofthe land licensed. Received ......... ..............2010......... �� (Signature) By ....................................... ...................................................... (Official Title) (Clerk) (State whether owner,occupant or holder) ...................................................... (Address) Proof of Coverages Search Page 1 of 1 Labor and Workforce Developme Date Last Updated: 3/2 312 01 0 Navigation Links Workers' Compensation Proof of Coverage - Employer Details POC Disclaimer _.._ New POC Search Employer Name: GENESIS HEALTHCARE CORPORATION/CAPITAL REGION GENESIS ELDERCARE LLC Report Atltlros• 140 PRESCOTT STREET WofkplaCe Fraud Cityrrown: NORTH ANDOVER MA 01845 Wk� Page 1 or, f< t > » Debarm' nt Insurer Policy Term L�t LIBERTY INS CORP 9 1]]S LISBON RD OS/01/2009 OS/01/2010LEWISTON,ME 04240 LIBERTY INS CORP 8 1775 LISBON RD OSM1/2008 O5/01woll Education Links LEWISTON,ME 04240 Who Needs WC Insurance? Ilt' < ) >)'.. Employer's Guide to WC Employers FAGS About WC Limitations of Search Res7rk Injured Worker's Guide to WC This Proof of Coverage Application allows the public to orkers'compensation insurance coverage Information for polici Voluntary Market Injured Worker'a FAOs About and Assigned Risk Pool. Do not assume that an employeating without WC coverage if your search results do not return policy infor An employer maystill have a valid workers'compensation policy under a d business name or Related Links may have an alternate method of coverage which including as as selfinsurer or membership in a self insurance group.Use theng links to view Experence Rating History listings of Self-I d E I /PDFI and$air rPEwrcel inMassachusetts. Connegicut POC Search New Hampshire POC Search With limited exceptions,every employer in the Commonweat with one or more employee(s)is required by law to have a valid workers' compensation insurance New York POC Search policy at all times.If you are unable to find an employer or suspect an employer is ClasaRcation Request Farm wrongfully operating without workers'compensation insurance, please submit a Wars'Compensa/on Inv d a I _RffeRral�m or contact the Office of Investigations at 617-727-4900 x214 or toll free at 1-877-MASSAFE(627-7233). http://64.73.57.96/Details.aspx 3/23/2010 A��y s;�••:srr.< C�1M.0 �Q�11N)t4I7.4ZP.O.LGiL OL ¢�f[CdCK6 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 30,2009. (City of 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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 orior to July 1,1936, Otherwise by the owner or occupant of the land licensed. Received C)aY d.Q.QZf.........2009....... . ................ ..... By6i w ' (O..R.... . .......... ........(..m.t.e.w...e.t.e.r..... . ....... ............ cial Tide) ckk) ow .,aceuPan or holder) ...................................................... (Address) 04/30/2009 12:08 9786872665 PRESCOTT GENESIS NA PAGE 01/01 The Commonwealth ofMassaehuserts - Department of Industrial Accidents MarAMMAWr 600 Washington S4rea Boston,Mass 02111 Wwkgn, Cmpensaflao huvaaee hlBdavk-Genera)MRWAn P c' El I en a axle praprie and have no one BaAnm Type: ReuT Pw—t==VBwMzdng D.su6ud malt wvrkill in nay csPamtY. �O®ce Sala(ihelwha'Real Pataft Aoias ae.) I am m tmDloya with mPloyers(fo0 k Part nme). Other N nt n., U 0m•2 :. -I-.m t ,playe<p ovrdi19 wakes'c ,pangti n for my ouplaym Wkind as tha,ph. _ +� H 1thC C tat' n/PresMMOM cott House - 1 140 82escOtt Street' Bortk Eeedink M: Dig45 .hradY (978) 685-8086 . 1. ... . , _ ; ._... . ..: _ , .. _ [am a ade pmpri sad have hired the ipdtymdeot taiatrsaaa lined below who have the tbllowivs wakes' compmsadu polieat . . r. . sits e. irR ins P.a...ru.N.eNn.pnngvY'a oeN P.etlw lsAAMfA.137m Wr xe.1 P M- -F 1 1P HW as err-Y al MO .NrNn•�.oNIN a.a N.rdt...t+r.r y rrr N.Pros wORY OaDOI si.ffr Na1MN.4r•prn r Ilar.r.a IY.. e.prdWr.rl"s�sr�rke 4nrHdr u.amN NIwNeP1.�Na.aGMenr.p..rmsurw f le koroby.gep^.\ )rM �M�' ^�r�f�7 nsde GfN..rG.p>.rl+.l w.e6mN.1^d..nnt gin pri.tam SLUA.QA �l1LOC� PhPa.P 4�� lokSgD�(ln .Illerlme N4 MW[Nl4r alY nr 4lwn�YtM by."N W.-Mbd ❑rY/dNr ebkw Y.1:m W44 rrpor°k rMxtlrd Pr.rw9h.r.I Qt1..M1W� W N os,e0 (]nNMNwa NnlNr psrwx PWm M. (]Oiker Note: COMPlets top of form and forward both sections and fee to local licensing authority (C1ty or Town Clerk), Do not make a licaticn to de aron PP P ent of Public Safety. � �oarnmeo�racueat!�z o�l7�/laQa2c�ivaeCzy '=�T—^ a���'rne C�izuer�s _ 'L'�rtrueo�e o��iirs ✓�->.eumr�nw MY or Town NORTH ANDOVER 7 aca 4 ---- Date_ APPLICATION FOR CERTIFICATE OF REGISTRATION In rdanca with the provLsions of Chapter 1a8 Secdpn Ia. of the General Laws, the undersigned hereby certifies that PRESCOTT HOUSE REST is the holder of licanse granted o/ /R t for the lawful use of the building(s)or other%mmure(s)sduatec or o.. to be situated at PRESCOTT STREET ea'elated to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABL_a OR EXPLO SIVES. OSIVES. Note: fiis application for camf1care of regisrrapon mum be signed by Me bolder of ate 972nfed pnor to July 1, 1936, Otherwbe by Me Owner or o=penr of /anti h e d swd hce0. was Received Submitted by _ by n Commonwealth of Massachusetts Ay. YI 3 4. 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 30,2008. (Cityor Town) (Detc) 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date):9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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 its ahi li a was granted prior July 1,1936, Otherwise by the owner or occupant of the land licensed. Received �f�....c78...........2008......... tq:........ ........... ..::...... ...........'.t.l1.M.61r (Si .. ....:.. �✓/'/��e�'/l,. �I d.,./ ........................ y (Omciul Title) (Clerk) •(Stne wh/e�awr owner,occupant or holder) �) (Address) . t The Commonwealth ojMassachusetts _ Department of Industrial Accidents AWf AfA wglbr~ _ 600 Washington Street Boston,Moss 01111 Workerf Cou ensatim intanaa Amd&*-Gen"Rusizaaa �fP� coif U " P ..t.b...r .w (�5arl�h flndoue r' Bata: i' ��rl ar iiEy ohtm.a 7n168s-8o 8C. , wk ate hpgm(fog.ddnrc [] r am a mle proprietor and have no one Businas Type: ❑Retail❑RcstauranVRW1Fating Establishment w rking in ray eapeelty. Office❑Salts(including Real Estate,Antos etc.) ®I am m tmdyor with I " enlployeas(fall &part time). E Otba - n I am an®Pb3or ptovldmg warxm'cmapeaatiun far my eavlya e working to this job. Y1`r ac,o4L H-Qu.S'e im, n)6c+b AnAAyert. Mh 01Y ,5— - tttm.at (49F) (o86-k6 ?� u Cn' WA q- 04 8 OPM I am a sole ptopridar and have hired the independent cuabaclars listed below who have the following wvkn a• compensatim polices: .ddr.u.• tv ohms de fa addax: io.ureoce seta F.INn roam.a.oamem ytodm Samdoo2bA.f MGL 1f2e.ebadb tha n^WItINNerlmlmipm.Mlm efm be•Pfo21.%LMadfor emy..n•imprlte•mml mwamadNaa.sYtm fotba formof.STOP wO ORDER.od.lim.rrl N.M.day.pimt r Imhnt.ed th.te ,.,.f thb etalaesot tmyb at.w.rr+t.the Oniea of ImmtlptYm of tb.DG for eavu.p..rBlntk a I do Aereby ratify p/taa mtdprn a/pn' ds infernafiao prsviJd abate is true mtd cer,e S(gsetme Dote - - -'i f Ph. .Mblme sdy do mttMh b thb am to he moviktrd by city or%oa omW say or to..a permitB4eom N �Bulldiea Deprtmem ClUcemina Board ❑cheekd�di.rerapaarbrequired OSelatavW.Othe OBorah Depar.m oo atvct pence: ph.m N; (]Other R.a.e srµ soon TOWN OF NORTH ANDOVER OFFICE OF TOWN CLERK 120 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 � M°ATM Joyce A. Bradshaw ♦•°.•; '� Town Clerk : Telephone(978)688-9501 FAX(978)688-9557 E-mail: ibradshawAtownofnorthandover com 2008 Renewal To All Above Ground and Underground Storage Tank License Holders: Enclosed please find your Registration Renewal Form(s)for above ground and/or underground storage tanks. Renewals are due April 30"of each yew. The fee for renewal is $150 per site. Please sign the top portion of the registration form and return it with the appropriate fee, payable to the Town of North Andover, 120 Main Street,North Andover, MA 01845. The bottom portion is Yours to be displayed alone with your license Also included is the requirement to provide an affidavit showing proof of Workman's Compensation Insurance. Please fill out and return the form to us with your renewal. Your immediate attention in this matter is greatly appreciated. Thank you for your continued cooperation. Please do not hesitate to contact me at the above listed phone number if you have any questions or need additional assistance. Very truly, p;� 67 Joyce Bradshaw Town Clerk Enc. The Commonwealth OfMassachusetts -_ - Department ojlndustrial Accidents 600 Washington Strew Boston, Mass 01111 Workers' C ar lanrsna Atsd>rvl[-General Bz"esuf v.em: Prescott House 140 Prescott Street city Forth Andover w NL4 01845 shom s978/685-8086 1 _ I>m a foie my capsic and hm ao one Badem'IYPe: Officc El Sales(including Real slaw Amos M.) worlun8 m any capamty. ® I am an®Ploys with , ,., anplo}as(fnH & art time). Botha I am se tmploya Ro`'dm6 kas'compensation fee my employee waling oo this job. _ cvm ev neve• Prescott House .dd.e..: 140 •Pre c ftl North A to a MA 01845 ehgvih 978/figs—AORfi ivnvvse 1,3b'ent 'Mutual Igmiranci, F, ^ - - I inn a sole pmpdcw and hove hired the iudepmdeat=U-dctas listed below who hm the RIluwisg workef' compeasatio polices+ coin v v. ho M addrer: P.fYn hrer.s..r.pr+`9�rr��afANffQ]Sdry YY YRIMIR d .v NrYI ftesrdtlrdvbrepY71,ALN�fhs �v/yr•Y'sbrrt r wdI r rMp�YY Y tlr fwr N.W'OP i{ORC OIID®lyd.es NfIMM.L1.PY••yr 1 v.dv.Yve tl.t. r�.r ay.hbev.eq.h.hrw.dd YlY. RbN]v.avpv.r N1b11G hs...r.p.wNrWa 7 d.lersbr srdfr�.lQ drtsivs s+rJ /�mim.p...Ld.e..eay.s a.l e...ert SigiNub Dde D /J J/o Z- Print m® Plvm t! .rnem re.vry a.e...�m Y d6.ru h be omplyd ear eur.e ann.MeW Ol.e.M a...+ ❑cheek u�eam�e ecP.n..s,eywem Osdrem.w.ome. (]Ae.eh peP.rtmevt .vmet Pm...: phone p; Elother (n+se aP ID®1 The Commonwealth of Massachusetts - — Department of Industrial Accidents AUMMANSAWMW 600 Wiashinglon Street Boston, Mass. 02111 Workers' Com ensation Insurance Affidavit-General Businesses i' vaae Presco[ sa: state: •i 5 hove# On— a sift location fu ' ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restawant/Bar/EatmB Esmblishmeat working in my capacity. ❑Office❑ Sales(including Real Estate,Autos de.) i am an an 1 with em to (Cull &part e . ❑Other I am an employer Providing workers'compeasation fumy employee,working on this Job. r".0.0y ve - Libe eddtts ' hove city- Bo - .11 Ivmravm go. r I am a sole proprietor and have hived the independent coutracmrs listed below who hm the$pBotnng workers' wmPentiatim polices: - mm en name• hove N• city Hen# iosarvvice eo. Dame• eddttss: hove N: ruv- lice ff inmrevee eo. F.dme to aec reovmmt Y wed a Y peminm W tb form of STOP WOIt%tORDER and v five of S1o0.OB v der Perot me�Ituodenmod thvt yr m Ye'm''mP he fenmrded temeO/ike sflmotlgvtbm sf the DlA for eevmge verlfkvtb¢ copy of thi+ataeemeot mvy y I do hereby.110 ry'fer the p°Y #.yn�penoh�e ofOerJwlih�tAe infirsallovprovided is frrt arAtorrtd Iktete Sigvaltve Phone# 97y 6Pr Puyb S.nt vats otnehl me eely M rot write Iv tm orr b M esmpMbd ti elry or towe emcivl 'r-nonc..# De❑BuBdive paremeW city or tows: (]Leceming Beard ❑&Icco oo."Office check if immedbh repeme b re9�ed Elnmith Deparlmevt phone 8; ❑Other ontactpenoo: (rt�xd9gt aM ___. Note; Complete top of form and forward both sections and fee to local licensing authority (City or Town Clerk). 00 not make application to department of PuUFO blic Safery �rirnirreaouuea�c �Gi�GczQaacluiae�`i c5", _ !� o� vre ✓-rmue><lian City or 0 wn NOgTH=g Dam R I w APPLICATION FOR CERTIFICATE OF REGISTRATION In abooft h,,with the Provisions of Chapter 148, Section 12, of the General Laws, the undersigned hereby certifies that PRESCOTT HOUSE .w�.amv avow EET �. is the holder of license gryrted_g_[�71e 1 for the Wwlul use of the building(s)or Omer structure(s)situated or to be situated at 140 PRESCOTT STREET as related to the KEEPING. STORAGE MANUFACTURE OR SA a F FLAMMAeLES OR EXPLOSIVES. croa Nate: Me app4'cadon/car deltl6gte dl "Pern"non must be signed by me holder of m gravhredodor fd Juty 1, 1926, omevwise by Ne owner or ocopant al a I f l �'r(as Receweo lJ 2.7 E U(e �G s Submitted by by S Y\e a BankefAmerica -%j Personal Money Order No. 0295803 vop nrreat no n Otis ,` MORTN ANDDpMR . ,.MARCH 27, 2006. 3a11ne1, NTX mh, ouf v "ONH HUNDRED PIYTY DOLLARS AND 00 CENTS" $ **150.00*L*AC 16<44954se x $ Not valid Over$L000 i YlOAA � i A>oP+agL&Wt ha6le fodost orswlen spy 0p6 OgA��etbap mlpt@,�sm1 ��"" b �� MH4}YMP�BgD�n*4•••sTof•T +8@ue4b �� a vu � 1 S-Ap Tk . > •0295El03 • •: LL4000019,: 00L641005362n• N� THE ORIGWAL IJOCIIMSNT HAS REELSCTNB W&7MtRAE1 ON THE BACK THE[1$IGBVn DCeUMENT HAS BEK&OTI,WATEBMA,K M TWaACK. M 1 (11 I V I TOWN OF NORTEPANDOVER OFFICE OF TOWN CLERK 120 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 o' poaTN,N i } r O Joyce A.Bradshaw t ' � Telephone(978)688-950 1 Town Clerk - " FAX(978)688-9557 Prescott House 140 Prescott Street North Andover, MA 01845 - March 16,2006 To Whom It May Concern: Enclosed please find your 2006 Registration Renewal Form(s) for above ground and/or underground storage tanks listed at the address(es)on the enclosed form(s). Renewals are due April 301h of each year. The fee for renewal is $150 per site. Please sign the top portion of the registration form and return it with the appropriate fee, payable to the Town of North Andover, 120 Main Street,North Andover,MA 01845. The bottom portion is yours to be displayed along with your license. Your immediate attention in this matter is greatly appreciated. /Very truly,' v Joyce Bradshaw Town Clerk Enc. Nate: Complete top of form and forward both sections and fee to local licensing autherdy (City or TownnClClerkl. Do not makesappFpllicadon�todeepartment of Public Safety. (qg� � �7t (OL�7Z7IZOiI2dlJ2Q.Gl�i O�/T7V/�GCLJdCLCi7✓u62CliJ- 2 Je�%arGrnexCo��—'vre �vxveeas — L'vwuox a��vre ✓�'nauerzCean ��nn Cltyar Town NORTH ANDOVER Date 4yl CAl APPLICATION FOR CERTIFICATE OF REGISTRATION In a=fdanm with the pramsions of Chapter 148. Section 13. of the General Laws, the undersigned hereby certifies that PRESCOTT HOUSE 1L0 PRFRQOTT STREET is he holder of license granted 011.7 1RI-for the lawful use of he building(s)Or other 4nrGure(s)stuared or to be situated at _ _140 PRESCOTT STREET as related to the KE?ING, STORAGE MANUFACTURE OR SAL OF FLAMMASLES OR EXPLOSIVES. ran a ATmnVC➢ MA nIghs rwa7o.. Note: The application/or ceraficare of regiscrisaon must be signed by the holder of the frcanse if said license was granted Prior July 1, 1936, emerwee by he owner ar occupant of Me land ficensed. Received Submitted by by pram rw ,m... _--------------------------------------------_ � _ �comvrreea2cueaCCLc r�C/�/�waczc`ucaeC7a e" eftanrlmtertCo� vre e�ices — vn.¢�en V C/an/cgp Cityor Town NORTH ANDOVER Date REGISTRATION Thwp to cartify that PRESCOTT HOUSE ..wmw has, in accordance with the provisions of Chapter 148, Section 13, of the General Laws, filed with me a cerfificate of regismation setting forth that PRESCOTT HOUSE is the holder of the license grained 9/17/81 ob for the lawful use of the buiiding(s)or other structure(s) situated or e tc be situated at 1411 PRESCOTT STREET NORTH ANDOVER MA 01845 snw.m,�w. as related to me KEEPING, STORAGE MANUFACTURE OR SAL OF FLAMMASLES OR EXPLOSIVES. so.n..w omw r Note:A certificate of regerrdeon must be filed on or before Apra 30m of esen year. THIS REGISTRATION MUST BE CONSPICUOUSLY POST ED ON THE PREMISE'S F'5(neasm r56) e TOWN OF NORTH ANDOVER OFFICE OF THE TOWN CLERK 120 MAIN STREET NORTH ANDOVER,MASSACHUSETTS 01845 Joyce A.Bradshaw,CMMC Telephone(978)688-9501 Town Clerk G Fax (979)688-9557 ma6 Bradshaw@towaotnorlhand a om FACSIMILE TRANSMITTAL FORM DATE: /I1 szF o20 �700 S ADDRESSEE: NAME: FIRM: STREET: CITY: FAX NUM: to.9'/- �././- FROM: NAME: JOYCE A.BRADSHAW, CMMC DEPT.: TOWN CLERK 120 MAIN STREET NORTH ANDOVER,MA 01845 TELEPHONE: (978) 688.9501 FAX NUMBER: (978) 688-9557 TOTAL NUMBER OF PAGES, INCLUDING COVER LETTER: L3 ADDITIONAL COMMENTS: pp � G;eA�ilarcf .1o2iiy� Nate: Complete top of form and forward both sections and fee to local licensing L authority (City or Town Clerk). Do not make application to department of Public Safety. VJG i72'/YGO'/ZCI�JyBQ�i 0�.�C�r�//CQQaCLC1ZCl62G�.1 � � �rr�iarG.na�tt o�C�isii,.e GJrpurcea— L'iitwuarr. o�}ririirs ✓�ieuereGian Cayor Town _NORTH ANDOVER Date IL� j APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 148.Section 13. of the General Laws, the undersigned hereby certifias that PRESCOTT HOUSE ....dnavueaw , 140 PRESCOTT STREET .mw is the holder of license granted a L,171Rl for the lawful use of the building(s)or other snutture(s)situated or to be situated at _ 140 PRESCOTT STREET sw..c.v.mr as related to the KEEPING, STORAGE MANUFACTURE OR SAL OF FLAMMASLES OR EXPLOSIVES. Nora: This appFczGon for cerbficare of regisuabon must be signed by the holder of the license if said license was granted �poor to July 1, 1936,othmv re by the owner or ocupanr of the licensed. Recewed "\' Submitted by �L /No `76.e r.,.7T rT ST Al, A A e_7?�•g _ _ � �c'ammzo�cuea�C r�c'�/�aaaac`u�ael�• }���,,, _� �r�����re•rxcet —�'Liedex�aourad-JC�'Cara�s c=�� ✓, City ar Town NORTH ANDOVER Date Il, da,J REGISTRATION Tis is tocsrafy that PRESCOTT HOUSE ate...... has. in=rdenca wM the provisions of Chapter 148, Section 13, of the General Laws, filed with me a certificate of registration setting lam that PRESCOTT HOUSE o the battler of the license granted 9717 781 0� for the lawful use of the building(s)or other structure(s)situated or to be situated at IAQ PRESCOTT STREET NORTH ANDOVER MA 01845 sne.. as related to the KEEPING, STORAGE MANUFACTURE OR SAL OF FLAMMABLS OR EXPLOSIVES. Nora:AcaroaGre at reparato mac be filed an ar before Apr830M of sear year. THIS REGISTRATION MUST SE CONSPICUOUSLY POSTED ON THE PREMISES I.]5Bl Fa OTHE, J, Vi6W TPVE WPT PMA OID WeIA®IF1W 1q G4YXY MONEY ORDER merRca � - * 703750124 ,iRORTR AODOVIA No.IL 22, 2005E,o,"j-4, n_ Y• "TM001 o000R00 PIP7! DOLLAAB ArD 00 C1R8" 150.t>D n4000DoI] LJ�.abrcge-�� e 0012712 00"1 70375012/ §C o1.f S�• No A,�dOvcr/.1A01845 1" 55500011' 1: L021ootboi: 68000 70 3 7 50i2R.n• Note: Complete top of farm and forward both sections and fee to local lioansing authority(City or Town Clerk). Oo not make application to dep artment of Public Saf ry �+ -i �O�m��rnao¢crf�jer2GG/L a��/�ad6aar�� �e��yC�i''vw Ve.•w.ces — �wiao-ro �in+e �ireye�eCsan Cay or Town NORTH `ANNpOVEg Cale ce IL APPLICATION FOR CERTIFICATE OF REGISTRATION in aCCordan with the P�IdCr*of Chapter 1A8, Sectfon lZ of the Genenaf Laws, the undersigned hereby carafies that PRESCOTT HOUSE n•«.annvuiov. R ET a the holder of license granted_g/t /p 1 for the lawful use of the building(s)or other vrucrure(s)situated or to be situated at . 140 PRESCOTT STREET as refaced to the KE_.'a r�AMMA ING, $TOgAGE. MANUFACTURE OR SALE OF Fl.AMMAELES OR EXPLOSIVES. Note: Th/s aPPI=Dcn for camfla re at reg/smlibn muv be signed by the holder o/the h6ame it sold 6Gens w ,granted poor to Juty 1, 7936, "name"by the owner Or=¢ Panr of the l%Censad. e as Receivedp�i Submitted by by n � Tilllly� l 1�n t mn ^�, '� f —B�,•, s t42a .er,.J2E A —————————————— Note: Camplete tap of forth and forward both sections and fee to local licensing autharity(CRY or To%m C lerk). Do not snake application to department of Public Safety. (6 � �Oamirrw�rucuyea,�Lc ay�OTn�/�aaaac�uiae?t�t �e�anrGine�eCo��^'vre CJezw.cm _ L'rilaeo-n o��iirs ✓'KauereG.asc Chyar Town NORTH ANDOVER Date n IL APPLICATION FOR CERTIFICATE OF REGISTRATION In eco rdance with the provisions of Chapter 148.Section 13. of the General Laws, the undersigned hereby certifies than PRESCOTT HOUSE ».».amv»row ILO PRFSCOTT STREET .yam... is the holder of license granted q/1 7/R 1 -for the lawful use of the building(s) or other structure(s) ,tuar,,or to be satiated at 140 PRESCOTT STREET sa.»»»nmas as related to the KEEPING,STORAGE, MANUFACTURE OR SAL OF FLAMMABLES OR EXPLOSIVES. NQ Nore: This appllCadOn for ce,d6tlre of mgisfmaon must be signed by the holder of the Gcanse it said Ilaemse was granted pnor to Jury 1, 19-76, oflcmwe by the owner or ocup wr at me lard lkamn d. Received Submitted by by w»e . ___—_--------------------------- m � _t (kj lL'O�/Y1/n2U'ItL(JCuCLGG/Z C��%UCQQQCLCi7�W.1 '�'geCenCo�C-�vxe Cexriices—�.YouindC�Cara�e ✓xogrom:. City or Town NORTH ANDOVER pate FII, REGISTRATION Ts isto certHy,that PRESCOTT HOUSE r,a»wnamr has, in arardance with me provisions of Chapter 148, Section 13,of the General Laws, filed with me a certificate of registration setting form Nat PRESCOTT HOUSE is the holder of the license granted 9/17/81 for the lawful use of the building(s)s or other struru o». 9O re(s)situated or to be situated at 1 Ln PRFSCOTT STREET NORTH ANDOVER MA 01845 5u..e+avn»Z as related to the KEEPING, STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. e� 0. ibe�- sm»»»»»orm ra. Note'A carorlm Of mtirslhlb w must be Serf on or before Apnl 30M of eeeh yell,. THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES !nvicem>5fi1 4/22/2005 11 : 35 AM PAGE 2/002 LMG I L40 esco-W Spree+ a.unoe, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND GONfERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE PO4GYAN0 DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. This is to Certif,that PRODUCER OF RECORD: GENESIS gofth,c :[DATf:D SER�TCE A9NUTEMAN INSURANCE AGCY INC PO BOX 1 76 BLANCHARD RD LEXINGI02424) BURLINGTON,MA. 01803 At the issue date cenifiute, insured by tho Company under Cle pchcy(ies)listed below, The insurance afforded by Bre listed O,cy(iec)is subject to all Meil'temrs.euluslons antl condfims antl is not altered by any requirement term or cmdifim of any contract Or other document yith res Et to yfiich this cerfificate ma W issued. TYPE OF POLICY POLICY DATE POLICY NUMBER LIMITS OF LIABILITY Goyeraga AffoNed UnderWC COV. B Lau of Pe Follwing Saks 01/1612005 WC231S-333642- MA Bodily Injury By IN 01/1612006 185 Accident Each 51,000,000 Accident COMPENSATION Bodily 1 njury By Disease Each $1 000 000 Person $1,000,000 Policy GENERAL Lm6 General Aggregate-Ot el than Prod/Completed Ops LIABILITY $ Protl 0:17CZ:7ST ed Opera tlons Aggregate N/A N/A Bodily Injury antl Property Damage Liability Per Person/ OCCURRENCE Organimtim AUTOMOBILE LIABILITY l Each gcciden Single Limil- B.I.And Cum Mnetl OWNED Each Person ❑ NON-OWNED N/A N/A Each AGadent or Occurrence HIRED Each Accident or Occurrence OTHER LOCATION(S)OF OPERATIONS 8 JOB#(IF APPLI CABLE) COVERAGE IS RESTRICTED TO EMPLOYEES LEASED TO: NORTHEAST EXECUTIVE JET LLC NOTICE OF AN<E p qN4 O O. T E 4BOVE]E G319EC 0. IE- 9E C4NCELL C 9 CRE THEE E RPT.CYECii_rT E EOF nE T VG C ITE r0.+a�- b'L. EM1C p 0 C TEN NO E O TyE CeR .pTE H.F1 Rg So 6ELOn _rV1.' C3Gc GJ OH. 3E�• C eA ON TEE CCMP M' T'oEGEf:2 CRREo BIT GPICRE PC ML'L RUC V0,CE E,, n.pC._ FC RECENTAT'.SC LIBERTY MUTUAL NSURANCE GROUP TOWN OF NORTH ANDOVER OFFICE OF THE TOWN CLERK 120 MAIN ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 PORTSMOUTH NH DATE ISSUED 04/20/2005 Thlscedifirareisexecuted by LIBERTY MUTUAL INSURANCE GROUP asrespectssuciT insurance as is aforded by Those Companies ES 772R6 Lnc _ 4/22/2005 11 :35 AM PAGE 1/002 LMG 0 Liberty Mutual.. FAX COVER SHEET Date: Friday, April 22, 2005 To: TOWN CLERK Fax#: 978-688-9556 From: Robin Van Wallenburg Phone#: Fax#: 603-431-5693 Pages (including cover): 02 Notes: Note: Complete top of form and forward both sections and tea to local licensing e� authority(City or Town Clerk). Do not make application to department /of Public Safety. � �\ �(YI)7/lY[•4iI7.G!/2pLWG O�VI�CCr44CtG/LU62ryry�y �e`[O/MCIfLB1LC 6`V"NrB C:INWLGCb — �Uf/r01,6�L p�V'r X6 Cltyor Town NORTH ANDOVER Date 1MR/1- ,30, g'CYYL3 APPLICATION FOR CERTIFICATE OF REGISTRATION In acardancs with the provision of Chapter 148, Section 13, of the General Laws, the undersigned hereby caNfes that PRESCOTT HOUSE wm.amara wa.. 140 PRFSPOTT STREET - .ome. 4 the holder of license granted Q 11 T1 1RI—for the lawful use of the building(s)or other structure(s)situated or to be situated at 140 PRESCOTT STREET ^ as labeled to Me KE=?ING, STORAGE,MANUFACTURE OR SAL OF FLAMMABLES OR EXPLOSIVES Note: This applimnpn for camrate of mgisnzfcn must be signed by the holder o1 the 6cane if said license was granted pncr to July 1, 1936, omenvfae by the owner or occupant of the la dIrc3r ed. Revived CZ /., J= a�f^?CYL� Submittddtee by ., by Q 2r f sC . Fd.i'", --------------------------- ---- 1270 HOME, INC.SING HOME csa+aoszas , .PRESCOTT NURSING NUR _ — --DBA PRE$COTT HOU$E. cArs � :-.IQ PfiESCOTT &T 0 Y, m L NORTH ANDOyER J,+A -. rAT 2OTtla oaDaa o. W DOLLAR5 s O Fleet a-�ZRAt�E.(AN�.eH r!r S M11°" 0 032631t' 1270 a:0 L L000 i 38t. `O 50 Note; Complete top of farm and forward both sections and tee to local licensing authority (City or Town Clerk). Do not make application to department of Public Salary. .Tra _I UJU'IP7/I320�/ZL�lIy2aGL/2 0����t7�,000LC/LtCQ6�,l � LeJea�GmamCa`�'urm c-Jv+rvicm — L'inraiuie o��riKe �Aruarttron City Or Town NORTH ANDOVER Oate4esz o7Q9o1 APPLICATION FOR CERTIFICATE OF REGISTRATION in accordance with me pnOiiiu om of Chapter I18, Section 13, of the General Laws, the undersigned hereby cemlies that PRESCOTT HOUSE ILO PRESCOTT STREET is me holder of license granted_Q 11 t1 191 for the lawful use of the building(s)or other structures) situated or :o oe situated at 140 PRESCOTT STREET as related to me KEEPING, STORAGE, MANUFACTURE CA SAL OF FLAMMASLES OR EXPLOSIVES. None: Thu applfWdpn/or cerdBcare of registration must be signed by me raider of the license if said license was granted prior ro July 1, 1905, otherwise by the Owner or=R pert of the land licensed. Aminvea , Submitted by y n ov ----------- — Ta //-� ,�O1m7/IYLO�ZL(JBCLGG/Z C//I✓I�Gadd(jLCx"--1z S 9' =� �1tBflt6`�r1'vw I�BOr'+/(C61 — �/�R.6CwL,.a�V�0Y6ge�JtNIK ,/ Xotr?'2in, J c C Clty Or Town NORTH ANDOVER Oate APAUC 30.c'�Da REGISTRATION -had ro cemry mat PRESCOTT HOUSE mo. raz. in acardance with the provisions of Chapter IAS. Section 13. of the General Laws, filed with me a carti8cate of registration setting knb dal PRESCOTT HOUSE u the holder of the license granted 9/17/81 for the lawful use of the building(s)Or other structure(s) situated or oa. :o ce situated at "n pgpSC2= STREET. NORTH ANDOVER 1 MA 01R45 Eaxwau 1; as related to the KEEPING, STORAGE MANUFACTURE OR SALE OF FLAMMASLES OR EXPLOSIVES. RNade�rduA- -� sy�aw...a aseu nw Nap:A came='.of ngl.Mear must be elan On Or bet"April JOM al each year '5ei , THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES innyaO ypRrM TOWN OF NORTH ANDOVER pf �1H n ♦ s Joyce A. Bradshaw,Towo Clerk TOWN BUB.DING ss,rwusE (508)688-9501 120 Main Street Fax(508)688-9556 North Andover,MA 01&45 March 31, 1997 Alan O. Solomont Prescott House 140 Prescott street North Andover,,MA 01845 Dear Sir: Enclosed please find your 1997 registration renewal form(s) for underground storage tanks. Renewals are due April 30th of each year. The current fee is $100 per site. Please sign the top portion of the registration form and return it with the appropriate fee payable to the Town of North Andover, 120 Main Street, North Andover, MA. The bottom portion is yours to be displayed along with your license. Your immediate attention in this matter is greatly appreciated. V/p/1y tru/I � d� � ♦ GlFxrese(.� �a'dVa3�'rctav Joyce A. Bradshaw, Town Clerk enc. JAB/je Note; Complete top of tam and farward both sections and fee to local licensing authority (City or Town Clerk). Do not make application to department of Public Safety. ,� _ r //� �emzrr�oaeccC�yea� a�/�7va�aaaaclucaellJ, 3. ;% Je�e2xGmemLao��'vre V nweces— L'vuiocoac o�C�'vrre ✓�'-i�ve�.can City or Town NORTH ANDOVER Date `i"""` r.3D iILYJ/ APPLICATION FOR CERTIFICATE OF REGISTRATION In acochimnae with the provisions of Chapter IAS. Season 13, of the General Laws, me undersigned hereoy comfies ;hat PRESCOTT HOUSE mm.a.m.sua... 140 PRESCOTT STREET a the holder of license granted Q/t n/R 1 _far the lawful use of the building(s) or other saua:ure(s)situated or to be situated at 140 PRESCOTT STREET snww�•. as reared to the KEEPING. STORAGE.MANUFACTURE OR SALE OF FLAMMAELES OR EXPLOSIVES. 99RTA ANnnncR MA O1 R45 C:vr r� Nere: i his app11=110n for certificate of regiSMIZOn must be signed oy me bolder of the licensed said license was granted pnarta July 1, 1935, otherwise ay the owner or=upant of the land licensed. Recaveo Suomitted by • vm.no. by --------------------------- ,--/----------------_ g �O7Y1/17ZdI2G(J2CLLGi2 GC�VI�(QQQpC r<t®j q �`efaamene 3 �vivxe Ver•zest -2Gixdex�nwuiirr� Cara�eC�am.c ✓"no�wnrp . City or Town NORTH ANDOVER Date Gvr�/. 30,p'Ooi REGISTRATION his u to certify that PRESCOTT HOUSE has, in accordance with the provisions of Chapter 148, Section 13. of the General Laws, filed with me a certificate of registration sebing forth that PRESCOTT HOUSE H the holder of the license granted 9/17/81 a.s tuC for the lawful use of the building(s)or other sture s)situated or to be situated at 1 LO PRPSCOTT STREET NORTH ANDOVER MA 01845 sow.,wn,mu. as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FFLLAMMASLES//O;;R EXPLOSIVES. q 60 . sue.w ons�r Note:A ceMRote of regrstraoan must oe filet an or aslant ApM 701h of each year. THIS REGISTRATION MUST HE CONSPICJOUSLY POS-ED ON THE PREMISES 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 DEPARTMENT OF PUBLIC SAFETY. The (tLomntm &ra[t4 of C?%n0 fjU6ettB Department of Public Safety—Division of Mre Prevention I CERTIFICATE OF REGISTRATION • ..NOXT.U.AbMQYEB.....................ARRSL..30>........ 19Ad ICIW w Tumnl (0.y1 .... In accordance with the provisions of Chapter I48, Section 13, of the General Laws, the undersigned hereby certifies that ALAN 0..,•SOLOMONT,,,{%RNSGRTx..RQUSEI......... Address .....1A0..PS.ESCOTT..RTREET.....NORT9..dN➢OAF&,...MA I N.mr o[naaer o/littn.el Is the holder of the license granted.........................SEETEM.gER..1,7.......................19....81for the lawful use of the building(s) or other structure(s) situated or to be situated at.....1.4.Q..ERESCATT..STREET............... N fall. uW ..lmol NDOVER u related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF FLMIMA13LF5 OR EXPLOSIVES. ORTH A .................................,.......... ....................................... -T ICily er a.nl No.;: Thi.cenifie.te of reainenion tno.t be,used by the holder of Ike 11,lol a if wid lieee.s..m,oled prior I.July 1. 1936,olherml.e by the osnv or—Ill nt of the Usti Ikented. Received ....................... ........................19........ ................................................... ........................................... by .......................................................................... ALAN 0. SOLOMONT (pRESCOTT HOUSE) . ..................................... ..........00pt.....1 Jlo..... lat.0 wlutp.r.mnre, :wp.nt.r ll.lderl...................... �•IOlnei�l�t'plel 140 PRESCOTT STREET, NORTH ANQOVER, MA 01845 . ........................................................................................... twaa..�l QTmttmmlfvra1f4 of sac4u.0&5 Department of Public Safety—Division of Mre Prevention REGISTRATION NQATH..A0.QRi:$.........._......APR1L...3.Q........ 19....9.7 ALAN 0 SOLOMONT Ieiy or To., mwl This is to certify that.....................:........ Q'ft.NT..(R)? SGQT7:..H9USh)...........has, in accordance with the Provisions of Chapter 148, Section 19, of the General Laws, flied with me a certificate of registration set- ting forth that....EaLP„I1..Q.,.,SA,S,Q.MRNT...(PBESCOTT.xOUSF.)..................I, the holder of the license granted ..............SEP. . .....TEMBER. . ...1.7.., ..................... ,..1s...81 for the lawful use of the building(s) or other structure(s) . . . .... . . . . situateC or to be situated at.........L40..PRESCOTT...STR6RT.,...NpRT1-.ANUf1YRRy.•h6q....................................IB 1. .ntl NomMrl as related to the KEEPING,STORAGE.MANLFACTURE 0 ALE OF IMABLES OR EXPLOSIVES. 5 51. �Q.d.Rrjf 7e, w 0,&74,r tl . .................................... �••I8(enuub.n 011lelY TIt41 Note: A cerlifieue of rcainmion oo,be filed on or before April 301h of e.eh roe. (THIS REGISTRATION MUST HE CONSPICUOUSLY POSTED ON THE PREMISES.) r 04`1 TOWN OF NORTH ANDOVER OFFICE OF TOWN CLERK 120 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 OT MO'TM 1y Joyce A.Bradshaw Town Clerk Telephone(978)688-9501 FAX(978)688-9556 April 10, 1998 Prescott Nursing Home 140 Prescott Street North Andover,MA 01845 Dear Sir: Enclosed please find your 1998 Registration Renewal Form(s)for underground storage tanks. Renewals are due April 30"of each year. The current fee is S 100.00 per site Please sign the top portion of the registration from and return it with the appropriate fee, Payable to the Town of North Andover, 120 Main Street,North Andover,MA 01845. The bottom portion is yours to be displayed along with your license. Your immediate attention in this matter is greatly appreciated. Very truly, lc y L. Eaton, Assistant Town Clerk enc. Note: Complete top of tam and forward both sections and fee to local licensing authority (City or Town Clerk). Do not make application to department of Public Safety. �; �, �; �an7rmo�reusea✓� a��/�aaacrc�ivae� }+ �eJhanrGmexCo�C�'vre Vrwuceea — 1.'vwuon o��vxe ✓-man Cityor Town NORTH ANDOVER Date APRIL 30 1999 APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 148. Section 13, of the General Laws, the undersigned hereby cenlfies that ALAN 0. SOLOMONT (PRESCOTT NURSING HOME) .wysnm.dr�.. 140 PRESCOTT STREET .eA.n is the holder of license granted SEPTEMEER 17 1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at [4n 9RFCr'nTT CTRFFT SNf vq Amy as related to the KEEPING,STORAGE, MANUFACTURE OR SALE OF FLAMMASLES OR IXPLOSIVES, NORTH ANDOVER urs rAm Note:This aPPliraoon for cero(tate of registration must bs 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. Received Submitted by aA by AmA oear nth my _----------------------------------- � _ � �eo�mimaruuealG`c a��laaaacluaeCZ�i a�il 91 Je�icrrGmenta� irs Gg'eanreies — V C�am�c ✓"xar�nammc City or Town NORTH ANDOVER Daps APRIL 30, 1999 REGISTRATION ihls is to certify that ALAN 0. SOLOMONT (PRESCOTT NURSING HOME) uay.m. has, in accordance with the provisions of Chapter 148, Section 13, of the General Laws, tiled with me a certificate of registration Setting forth that ALAN 0. SOLOMONT (PRESCOTT NURSING HOME) is the holder of the license granted SEPTEMBER 17, 1981 for the lawful use of the building(s)or other stwcture(s)situated or or to be situated at 140 PRESCOTT STREET, NORTH ANDOVER, MA sevme Amy as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF F AMMABLES OR EXPLOSIVES. �iz. Cl. 1Qo�.Cs9.r�u ��rx Ool� yl1 Nate:A cartlbtlre or registration must be 91ed on wbeiare Aprd 30fh of eaCi year THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES TOWN OF NORTH ANDOVER OFFICE OF TOWN CLERK 120 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 O�N�er�ENO Joyce A.Bradshaw Town Clerk o Telephone(978)688-9501 ^�y FAX(978)688-9556 'y�ss+crust` March 29, 1999 Prescott House 140 Prescott Street North Andover,MA01845 Dear Sir: Enclosed please find your 1999 Registration Renewal Form(s)for underground storage tank(s). Renewals are due April 3&of each year. The current fee is S 100.00 per site. Please sign the top portion of the registration form and return it with the appropriate fee,payable to the Town of North Andover, 120 Main Street,North Andover,MA 01845. The bottom portion is yours to be displayed along with your license. Your immediate attention in this matter is greatly appreciated. Very truly, �anet , � r427— Assistant Town Clerk enc. Note: Complete top of fort and tar lewd both sections and fee to local licensing authority (City or Town Cierk). Do not make application to department of Public Safety. � � �riminw�racuea,� a�C-'/l�aaacze�uaeL�I a �' � rnent �ry Flvauices— ?� oura4on o��'vrs ;l�rerAslf�'pn Clty or Tawn NORTH ANDOVER OateAPRIL 30, 1998 APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions at Chapter 148. Section 13. of the General Laws. the undersigned hereby cerdli s that ALAN 0. SOLOMONT PRESCOTT NOSHING HOME) 140 PRESCOTT STREETw�'""� and is the holder of license granted _ SEPTEMBER 17, 1981 for the lawful use at the building(,)or other rnucmre(s)situated or to be situated at _ 140 PRFSCOTT STREET e as related to the KEEPING. STORAGE MANUFACTURE OR SALE OF FLAMMASLES OR EXPLOSIVES. NORTH ANDOVER cndr� Note: This WoAaadon for certificate at registration must be signed by the holder at the/;bens.if said license was granted phor to July 1, 1936, omerwrse by Nit owner or o¢uoant of the land licensed. Reserved Submitted by by aeeu l4O PRESCOTT STREET NORTH ANDOt ma. ER MA �yl ---- �a�rrUrrzr/rzcae r�� �� �'' 3a' �e�late'rtCo��vx. �ezritces — L�indez •-.err-umr�.-`�toaa�e c�Qin� ✓xo�wzrn. - Cityor Town NORTH ANDOVER Oat, APRIL 30, 1998 REGISTRATION This is to certify that ALM 0, SOLOMONT (PRESCOTT NURSING HOME) has, in alXardance with the pmvisians of Chapter 148, Section 13, of the General Laws. filed with me a certificate of recauraficn setting forth that ALAN 0. SOLOMONT (PRESCOTT NURSING HOME) e the holder of the license granted SEPTEMBER 17 198w1w for the lawful use of the buiiding(s) or other shucmre(s)situated or to be situated at 140 PRESCOTT STREET NORTH ANDOVFR MA 0184 swr,m��,w aS related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMAELES OR EXPLOSIVES. ice s /i/Yf Q44) m Da�A s�r.m..vomor r Note:A cxm6ore of m]rsmbm muer be Ned an w bobl,Aonl'70 a/9en year. THIS REGIS T RATICN MUST EE CONSPICUOUSLY POSTED ON THE PREMISES P-5(raNsea]%1 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 DEPARTMENT OF PUBLIC SAFETY. The &MMauf calJ4 of 49no rfluotfts Department of Public Safety—Division of Mre Prevention CERTIFICATE OF REGISTRATION NORTH ANDOVEwR — APRIL 30. . ..... . ... ........ (oil, or Toe) .Ipei 1995 In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ALAN 0.........SOLOMONT (PRESCOTT.,_HOUSE)pddress 140,_P1.j)iSCOTT,,,$,�,,,,,,,,p]ART}j„ANDOVERA., MA ............. . .. .............. ,...i hold.,of s«r.el SEPTEMBER 17 81 is the holder of the license granted..........................................................................19........for the lawful use of the building(s) or other structure(a) situated or to be situated at....................140„ R.ESC.OTT„ST. (aw.a seaamehrl . .• as related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF FLA 1MABLES OR EXPLOSIVES. NORTH ANDOVER,,,,,,,,,,,,,,,,,,, 500 GALS DIESEL FUEL . . . .............. ...... clt.or T.an, Note: This certificate of reaisteatien must be ripsd by the holder of the firers.if ssid liceere w..seamed prior to July 1, 1936,mhmwi.e by the owner or occurynt of the End lieensed. Received ..................................................19........ .............................................................................................. ,sla salsa by ...................................................I...................... .............................................................................................. ................................................................................ loll...�n.wr.wm.. ....psm er mlaul tomc�a Tuul .............................................................................................. (Add—) �l1�E �IIY[II1tDYTf1IEFt� D� 58FiL�1iSEffB Department of Public Safety—Division of FSre Prevention t REGISTRATION NORTH ANDOVER — APRIL 30 , 95 . .. ........................................................ 19........ M1,.r Tew,tl (D..) This is to certify that..ALAN O: SOLOMONT (PREECOTT .HOUSE) hu in accordance.with the provisions of Chavvlet 348, Section 13 of the General Laws filed with me a certificate of registration set- t. g AI.AN 0. SOLOMOIST (PRESCOTT HOUSE) is the holder of the license granted in forth that..................................................................................... SEPTEMBER 17 , 19..8L for the lawful use of the building(s) or other structure(s) ............................ situated or to be situated at.................................................140_.,PRESCOTT .STREET1...NORTH. ANDOVER,MA (Su.. s.d N.m1.n 500 GALS DIESEL FUEL w related to the KEEPING,STORAGE.MANLFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. .......................................................................................... I&rnsure..d OMe01 Tim) Note: A certificate of reelstrsJon must be filed on or before April 30th of wch year. (THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.) Nscpas �i 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 DEPARTMENT OF PUBLIC SAFETY. The (domma f tealth of c4ffkTssadjusPffs lugDepartment of Public Safety—Division of Are Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION NORTH.ADOVER........r_# 11..3o... 19........ fell, er T..n) - (De .)In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that .... Address ..... ............................ f the of license of li ran � • l7, 1981 is the holder of the license granted.................................................................. ... . 19........for the lawful use of the building(s) or other structure(a) situated or to be situated at...I. . F.4aF. t._$tw....................... (Soot aM winter) m rela ed to th1ee KEEPING STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. , - ...........NUTH...MYI R............................ 50D gals. Diesel Fuel, Note. Thi, certifia,te of rcsiatraion mmt be 4,ned by the holder of the lirenee if uid Iiren.e we.aearned prior to July 1, 1936.otherwise by the owner oe oeeupant of the land licen.ed. Received ..................................................19........ .............................................................................................. (aim.ln e) by .......................................................................... ........................................................................:....:................ .................................. ........................................ ISute whetter Diner.me.r.nl er Mwerl IO M00dJ Tlltel .............................................................................................. (Add—) (` [je Clomnlanfilettlflj ofGzssttcljuse#ts Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON REGIST ' b . ANDO.YER._A1_ ...... 19........ ICitr o.Tonn) to..) This is to certify that..♦] D � ...........has, in accordance with the provisions of Chapter 148, Section 13, of the General Laws, filed with me a certificate of registration set- ting forth thatlUAA&..Sll1mut(Preecutt.Emse).......................is the holder of the license granted Sept. 17d 1981 19........ for the lawful use of the building(s) or other structures) ............ . situated or to be situated at.....U0..h.*0Gott..$t..........................................................................................:. ISnat wwd Nomterl as related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF F IAB 1'pf'G IVES. Fuel Dale. Diesel ril ......................... ... .. ...�O� �r. .................. en.In.e..d .6.1 Tile) r Note: A r.niArme of rcGielraGon :n.n 6e filed on or before April 301h of rach yr. . (THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.) rnndwa swan nadl The Commonwealth of Massachusetts Department oflndustrial Accidents AUMOAMPION9M 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit-General Businesses syim�rr�'�� �ia' mil���.�/d�lu�i�a��i�la�aa� �iiv�ai'a�;✓�✓����,y�r.��v��{yHivn n.�x'w�.i �,y�io�,H,�,,,,,n cocoa Genec(s Hvalrb Cara addr,ear. 200 Brickstone Sq. Third floor t, Andover tdete: nra ic.01810 plants# 978-474-7500 work site location(hill ddra ), ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Reslaorant/Bar/Eating Establishment working in My capacity. ❑Office❑Sales(including Real Estate,Autos etc.) ❑ II um an um 1 with tan to full il arA rt e. ❑Other nursi U I am an employer providing workers' compensation form employees m P YH P g 1� Y P Y working on this job. comvavyvames Prescott. House addmas: 140 Prescott H,—o. ' itv- klaath Aadn�� Ma. 01815 ph #• 7A ivsuravee co, k berty Mutual ratu,vm Ilaa 630-004097-281 I am a sale proprietor and have hired We indepmdmt contractors lisied below who have the following workers' compensation polices: oomvenv vame: address city: h # insurance oo. IIe # enmpany Dame' address: ty_ honm p !us uravice to. Feaare to s«are eovenge n requtred ender Station 25A of MGL 152 can Ind to the impostdon of trlmiml pv.lnm ef.fine ap to rI,50a.09.od/Or Doe ynn'Imprhoammt y1 e fo vi aide pen.loo le the form efa fiam wOBIC OBDER evil a ver of ri00.00 a day.gaimt me. i uatlenmtd that. copy of thb abtemevt may be fnrmrded to the Offkeeflevodgatbm of theDGfortovenge verillcatiom !do hereby cedify un perydt*es�urythat the information provided above is"me and correct signature // 11 SS Date [. /i Ll. Print name r?" \.1 ae.s I'hove# J�� VL official roe ooly do tot write in tha arm to he completed by city or town amend cityor town: permallicome# OBuildiu De g parlmeet <heekm ImmedWte respome a requtred 1]Limming Board ElSelmtmeu'a Omce cannot peraom photo#; (]Amhh Department Onmm a=Dt Am) (]Other M�gln��re (.�l/r�t L.Qf)LDi.Or1ALtLQ LG{L OL (fGIfA[QP�d Department of Fire Services 5 Office of the State Fire Marshal P.O.Box 1025,State Road,Stow,MA 01775 CERTIFICATE OF REGISTRATION North Andover April 30,2012 (Cityor 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): Prescott House (ADDRESS): 140 Prescott Street is the holder of the license granted(Date): 9/17/1981 for the lawful use of the building(s)or other structure(s)situated or to be situated at (ADDRESS): 140 Prescott 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, ,A1 Otherwise by the owner or occupant of the land licensed. I ,, Received �.fRIG...a.0......2012......... ... ................ ,-- (Signature) By 1RRlIJC.I-ELK. ..............................Pan........ ) .............. (Off¢' Trtle) (Clerk) (state whether owned occu t or holder ...................................................... (Addrtw) The Commonwealth of Massachusetts Department of Industrial Accidents Mb �Rf4e 6go00 Washington Street Boston,Mass. 01111 —�' Workers, com ensatioa lluunatt AtBdaWe-General Btlflaew" vans. edNe err N d site omti Retail❑Restamznt/Ba/Eatm Establishment ❑ I am i sole my capac and have no one B¢daeaf 'h•Pe O Office❑Sales(including Real Estate,Antos III evtxldn6 sal'espaetty. ❑ I am an MI with em to full d: art time . ❑Otba I am tm employa providing warkes' eampe usenon for my®pleyeea wtabng on this job. y'{' O U. �Gc(1251 I�G'l�tite �,rrn ral[on d l4D �"Fi'es oaf": . . Her- Ijorfh P, ndove't- tMpr 0t845 eIx: �9lSl b85- 8086 iaal ' ,t<ui nc Ccm ccm Ir� N lU 7— (�, --Oo o - aPl I am a sole ptopriaar and have hired the independent contractors listed below who have the following wDrkas' compensatiaa polices; hove p. - city- Iwo ivmrvvee eo. Imams rom veviei . eddree•: heave N- ivevrvvee co. F.Wre r....m.e..enq r req�ed vvdm SaWa'SA NMI'1.352 n•led b err ImpeeeYv of erhvhrl Pater.f.ar oPM atN'ea.M.dl.r em ysn'legd,.vmme r nd m ef.apemher m ebe I.rm N•bTOP VrOPI:ORD[at ed•M.Nf]N.M•dar.pwt ma I mdeeebW the e - e.pl N W..e.mevt Mb Nrwvrded M1 the Oflke eflmrnptl.m Ntlr]tfAfir eorrageerih.eYa I dv hereby a rjjy mudc Pav de inlernoonev praoiGl abort v lr,r a1 rorreQ nm. St�otme /f�•--lam kmei/�g�l 066 �J'T 60V la � em atu.e oelP d.v.t erdtr V.ebb erm bhero�V+N bP efty er Wave efacW serd dty or nws ponW✓aeewN ❑Evndio•DepremeN (]t.ieemive b Clhee eh arr medlre rrp.vr Y regWred ❑aehxtm.v'e Othe Amah Depertmevt ovevct pen;•: ph..p; ❑Other rv..m av ID �L • (o q NOTE: COMPLETE T40 BOTTOM OF FORM AND FORWARD BOTH SECTIONS AND FEE TO LOCAL LICENSING AUTHORITY (CITY OR TOWN CLERK). S.,ieT DO NOT RETURN FORM TO DEPARTMENT OF PUBLIC SAFETY. the aDritri odalrafth of c ss"husiet#s Depa1'tlnent of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON '✓�9'�� CERTIFICATE OF REGISTRATION North dndoa�r............A.P.?:;U.�...................... 19...T.7. .............. (chy or Town) ratter In accordance with the provisions of Chapter 148, Section IS, of the General Laws, the undersigned her certifies that 0 a t Street...No. Andoni' Sha %roll,ReAP.r.s4'r?:W. 0... Address .................. F.....P!'a.....4.?t.................. ............... f t(Name or Fence gran . 19........for the lawful use Is the holder g( the license structed ure t..d or of the buildings) or other structure(s) actuated or to be situated at..l♦tPJsIMCOa ft rabor) tlfe-..-.-..-... as relatedd to the KEEPING,STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. ......Korth 6adover....... ............................................... 5,000 gala. fuel oil underground . ........... ITownl Note: This certificate le of rcsiauation must be niryed by the holder of the limme if naid Fpk. ru shorted to July 1. 1936,Whereat.by m 6s the o r or accupa of the lic Received /{�?....... .192�.. .......... ...... ... . ... .. ._............. store by .......................................................................... ...................................... ser.. . ........ ...... .... ............................... 18Hte vM1etM1er owner. oemgnl nr MNerl ................................:............... - .............................................................................................. IMEre�l S. dv NOTE: COMPLETE TdAND BOTTOM OF FORM AND I&WARD BOTH SECTIONS AND FEE TOTOCAL LICENNG AUTHORITYDO NOT RETURN FORM TO DEPA DEPARTMENT OF(MTY PUBLIC SAFETY.OR CLERK). zhe a mmotlfuRafth of +homhusft Department of Public Safety—Division of FSre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION North Andover April 30 76 .............................................................................. 19........ ICib er T.uD 10.41 ���� In acrrctto��rr�dance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned Sha I�ioll .�Flh Home(Dr.Guarini) ••,,,., Address 11t0,Prescott St. No. Andover ......................... .................................... .......... ............. . .................................... ...... . (N.n..f he —r 11--) d e 1Q$8,,,,,,,,,,,,,,,,,, ,, 19........for the Jawful use is the holder of the license granted..............?)ISt3s.... ........ o YliPrescott Stree................... of the building(a) or other structure(a) situated or to be situated at...........•.........•......•.....••. e IStrew eM nanMel as related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. ........................North,An4jov„@.F...................................... 5000 gals fuel oil underground ICib o.To..I - Nmt : Thi.eeeiaene of realuration xuu be ei by the hdde.of the Beth i 1 Ik d, vru pouted price w Julr 1, 19s6,oIher.ix br the o x upset of Ih li Received .19........(a�` ` ... . ..... by .......................................................................... .............................................................................................. ................................................................................ 1&.4.MlMr..ar,:xoxt or Fallen Ipa.IJ TIt41 .............................................................................................. IAllrcul ® il4r fQommonmra t4 of 913r{s>alarl�usettn Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ..North Andover..,,...April 30.•1975...... 19........ (Ci}ore T-1 (Date) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that S.his.JC?+aka..J3esS...Hame....1Rz...Sauar7ai)Addresa .]1ti0..ksescati..Si......Na...Andaxex................ (xsml n`ed.. Juna 9 1958 is the holder of the license granted.....................1.........................................................19........for the lawful use of the building(s) or other structure(s) situated or to be situated at....11y,0.Prescott„StA...................... (stet and some.) as related to.the KEEPING, STORAGE, MANUFACTURE OR BALE OF INFLAMMABLES OR EXPLOSIVES. ..................North Andover. . 5000 gals fuel oil underground, ........ ....................................................... (am w zow) Note:This eertileate of registration Moat be eig by the holder of the licease if said license was granted •prior to July 1.1936,otherwise by the or areupant of the la lice Received .............. 19........ .... .. ... .L�'�.Ln . 1..�.... JOHN J. LYONS, . (s,...W-) by .............. ...........TOE`rf•{3fi1....................... DOVER MA55 01849 ................................................................................................ ........................11Q../ ?..........t.........:....................... (store whe - o..ne.. oernoe,n o. howee) IameLl TML) .................................................................................... (Addeo.) iw Tantmomaralt4 of Massar4llatus Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ................lore I..AA gva.......tkl;AUJ!. t....... 19...7.4. (M: w Town) (Dew) In accordance with the provisions of Chapter 148, Section 13,of the General Laws,the undersigned hereby certifies that .....................8 ..g . .. B� e............... Address ...............1lI.Q..RA6.AG9tt..S4.................................. ��Iccc.� is the holder of the license granted..................J.IVAp....... a....MSQ...........................19........for the lawful use of the building(a) or other structure(a) situated or to be situated at......34o.. x=09.1t..Sb....................... (ae.em and nvm j as related to the KEEPING, STORAGE, MANUFACTURE OR BALE OF INFLAMMABLES OR EXPLOSIVES. ...........................flurLh.AndaV=.................................... (caa o. T.w.) Note: This certificate of registration most be signed by the holder of the Here" if said Rcener was granted prior to July 1,1936,otherwise by the r ocenpant of the nd li n ,.^ 7TZ Received ....... .. Y 19.. .. � .. . ........... . ... � .......................... ? by ......................................................................... ................................................................................ (slues wne[sec awnen omur.ve or someU (omext Woe) _ .................................................................................... (Add-0 go ((QA11i9Wt11UMO of ftwa 4nortts Department of Public Safety—Division of Fire Prevention u,p 3010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ....N4 a. ir.....Ap.Ii3..1..�Qr..19.7. ............ 19........ (city or Town) (Data) In accordance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned hereby certifies that 1(}0 Prescott St. Shady Knoll Rest.Aome...................... Address .......... .......................... ............................4.............. ..................... ... .................... (x.m. or sows a R.. -) June 9 1958 . . . .. is the holder of the license granted.....................a............................. ........ . . ........19........for the lawful use of the building(a) or other atructureSs) situated or to be situated at.14Q..1?:8599.:44..S.t............................. (Sa am nuns) as related to the BEEPING, STORAGE, MANUFACTURE OR BALE OF INFLAMMABLES OR EXPLOSIVES. ..........................NQa.AjuJA.Y.Qr.......................................... (Ci4 oe Toaa) Note: This eertiaute of m&tration mast 6e ei by the holder of the license if said license was granted prior to JOY I,1986,otherwise're the or oceapant of a la med� Received ..... ...... ..........19�'�... .. ... ..... .. .................... by ....................... ...... ... y�•�.............. ....................................................... (so-a .sane o.,n.r, ..enaane a noise) (061.W TiWI......................... .................................................................................... IAddrtul • • 6 Y 3 a 7 The (aomm ufoealth of guisachusetts Department of Public Safety—Division of FSre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ...........U.Q.e..AA1A.......H.P%'.7.1....3LlF...14:T2.... 19........ 031,m Town) (Dntel In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ...MiRd7..IAOU..Re.a.t...Ftnm.e..................... Address ......lh Preepett...Stle......U.T......Quar.1ni) 1 Name of holder of license) is the holder of the license granted..........J.U1Q...9.....1.95.d..................................19........for the lawful use of the building(a) or other structure(a) situated or to be situated at..UQ...l?3'if.S.QQ.tL..B.t.................. se(oo , nod nmnber) as related to t^he KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. .................... Q Ra... n+d.Q.v.Q.r......................................... (city ae Town) ''//�//////� Note; This ee,,I., t of Iy 1, 1936. Most b used by the odder of the se ifif eni sed, �'�nted yrfor to July 1, 1936,mheewiee by the ear aecupml of a End ad. )" Received ... ..... `.-�d.....................19.7.... .. .. /Zt.S... . .. . .. .. ..................... .... . by .................10H9..J,..{.Y( P5........................ TOWN CLE"fK .....................isui. .i..................... .................No,..Afm1 wli. . . ......................................... 1Araf5. Q1845 .............................................................................................. IAddrafet a • Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION NORTH ANDOVER APR 3 , ;,. ( 19._..... ..................................... . . ICW or Tow.l laael In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that .,,,Shady Knoll . (Dr. Guari ni............ Address ,140„Prescott E..,;,,,,,,,,,,„_„,,,,,,,,,,,,,,,,,,,,,,,,,,, . ....................................................... . ... . ............ ixv«.r hau.r.ni«..o June 9 , 1958 is the holder of the license granted..........................................................................19........for the lawful use of the building(s) or other structure(s) situated or to be situated at.....140 Pre9 co tt St. ..............n una b........................... (suer and mm�ber) as rgtylc EFsR RTM K {N6.8'F�K WE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. ..................L.'....................................................................... 5000 gals fuel oil ICiv or Tow., Nae: This cer ifienre of maiswtion must be sinned he holder of the Ikea.if said license wan aeannd prior w July 1, 1936,otherwise by the owu r acuWnt of th n�d li ` Received ................. ................................19........ .... .. �s�m.m,el by ................. IQHN....... ON LYS........................ TOWNCLERK ...................................................... ..................140:.. ;-A SR01BK................. q .............................................................................................. (Add—) 0 the ( ommort t A14 of Isstt huojet#s lug Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION �R 30197 NORTH.,ANDUVER........................... ;........ Iclty«Towel la.t.1 In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ......... ... ........ Dr. Philip.. G1dkjTi)ap....(3badAdBRai1.).................................................. .......... ................'...... 4..,..r bws.. .... 19........for the lawful use is the holder of the license granted...........:J!3CF@....9.���a• . . ..................... of the building(s) or other structure(s) situated or to be situated at......14Q... FBA.Gv.QpW.T+...S.Y�.............. nrt .a related to the KEEPING,STORAGE,MANUFACTURE OR SALE O gals s F INFLANDIAB oilEEi OR EXP Ound3 rtor�July 1, o iI Note: Thia tmi&.te of reaiatr.6on moat be ai ed h r oold`r Pam of the I dd 1 d P r 1936,otherwise . . :�.... ....................19.'.:.. . ..... 1J Received .._YF.'t.:`• ...LYOhS ...{. Islr..mr.i JOH NIt by .................TOW4--(; aK.......................... . .................................................................. .......................... . NO. iyNDOVER. MASS tst.0 wluNer.w....«000.m«mares .......:...:.................................................................... loarla Till.) I Addrce.l a 0 4Y3�1 toe QID1ttriWI[j tat of fflm"rijuseft$ Department of Public Safety—Division of Fire Prevention ' 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION worth A ..Andover April .15t1969 19........ u •• ••ic{V n.Townt tAYI In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that 1..Dr. F#11 dpiNT.ve n :1SLe«�v..X"11.)..... Address .........1.40..Frasootst..St..............4.................I........ June 9, 1958 is the holder of the license granted.................................................... 1 awful use ...a ...........Zff' �" aL.�t�tl. of the buildings) or other structure(s) situated or to be situated at..................n arol.................................. ,e.rnk ens n,„nenr, es rclu,ed w the KEEPING,STORAGE, MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. 5000..ga1s..fuel....ail..GtlA ,14..........Nor.tjx..@adover ICIry a.T...l N.,e: This roniarnte of rosimmion must be ix,,aCby the holder of the license if said lieensa wns/ennted prior w Jdr 1, 1936,otherwise hr the ee oecupnnt of th d 1•ee Received ............Qpri1....15...y19G.9......19........ .. .. ..... o. i{ �..... JOHN J. LYONS V r19 by ...........I'TOGIYW�UC.ERK. ......................... ,f... ........... . . . . . ...... I "............ ,9 whe,6er na. eesnsenl or MWrrl •AF`3DfiYilq�;••pf6Xtl G�l 5 YI lug Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ...._No. Andover........._AprSl..22............. 19..68 ...........Met,o.Tooa) (Date) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ..._Dr.r...PhiliP...Guam-ra...�.$. .5�9...Z110A41dreas ........14.Q...Fme.&aolt....S.t.................................... (Name of holder of)ieenra) is the holder of the license granted................ e....19.5.$..........................19........for the lawful use of the building(s) or other structure(s) situated or to be situated at...ILQ... ................. (St.a,W aster) as related ao the KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPIASIVES. „_North F,rrl o.yer 5000 F'als fuel oil. underground ICTowel Now This« me nf6e of registration most 6e maned by the holder of the license H said license rah aranted prior ao Julr 1, 1936,wheroke 67 t " nor oaccAuppaant of It end li . Received .... ........19........ ..... ..... . ..ECG( .......... &a amnl JOHN J. LYONS TOWN CLE;-:K .....................(Saar..ataa.erea...................r)a 1........................... 18dte vhathee ounce.«waant m holds) ....""""""'N6:'fiditGLi�F(tGR�'TJfA55:"OTII#T .............................................................................................. (AdA,eu) r 0 the (9=MWI(VW1#4 of ssxd*491 Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION North Aid over April 17. 19 , 67 ................................................................. . ICity or To�nl (0.bt In accordance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned hereb cer4�'fie that (Shady Doll) li}0 Pre soott st. Der. Ph1�liP.. Guarani......................... Address ....................................... ......................... ...... . .............. .......... ............................... . lisse INt a of license of gram 19„.,,...for the lawful use Is the holder of the license granted.......June QI ,l�j`�,„ of the building(s) or other structure(s) situated or to be situated at...�Q._.?rA .Q.Qt-t...S.Ye•r................ (sneer sad wanter) as related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. ...........N.Qx'_tkl..AA.d.aV.R1C........................ ..................... 5000 gals fuel oil. underground. ICht oeTwnl id Note:This renifir.le of selistu ah<rat b e ri sord by theorder he holder of 1 0(the e here.if I eensedre nns assented to Jdr 1. lo Recel . . ..A00........19c .............................................................................................. • es 181 t 1 m• ..................... MdKe r.wr.«wnsnt«bMerl...•••.......•....... ............................ .hjlt '6LE[�K.............. I,kl ...... .............................................. ............................................... NO. AND')VER. MC,B5• 0184 IAdd...n � 0 IL the ( =nt0dxert4 of '&So lraoe#s Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION No. An.dov a r....._April 30,.._jq. 6.. 19........ ICilr or Town) (o o.) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ....Ax'n...P,17.7. .$.8.... ...URr..7.Aj.............................. Address 140...PT.a&Cot.t..ASt......AShady...Kun11.......... (None of Adler of live.-) is the holder of the license granted.........??u?...4.s....1.9.0.................................t....19........for the lawful use of the building(a) or other stmeture(s) situated or to be situated at........, u,Q... ss3.SC.Rt.G...at............. (sweet a.s .,uaber) ce related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. Nor th...Ard RyAr.?..................................................5.000 gals fuel oil - undgrnd. (civ ar T—) Note This ceniante of 2 iarasion must bed ed the holder of she lima.if solid licence was need f tm on prior to JOT 1, 19a6,aherwine br th owe or oreupnnt of the d . Received ......i', .....z6...................19.Z.b.. . .. ... l.�'�-...... ... .... . ... . ......... . ...... ^1 J LYONS (sie..t.re) by .............J..:.::.i:.:..... TJ';"J t`ICI_�RIC........................ .............................................................................................. MFSS; isute.beaver oe..r. .re.o..t.r b.laerl ....................NO:..ANiI R1(. ..:..... ................. (UMIrIJ Title) .............................................................................................. (AU—) AL At (91mmOltfltta th Qf 4nns CChuuttB Department of Public Safety—Division of F9re Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ..North Andover........Ai3r.i.1...26............ 19..k5. I car or Sown) Coal.) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereb cert'li that i......�'h�lip...Narini........................ Address 140... .......(.Shadg..Itnoll�.... (name rr udder rr u..n,el ' is the holder of the license granted...iT!?R.e,,,Q,....19.5.8............................... ....... 19........for the lawful use of the building(s) or other structure(s) situated or to be situated at.... 0...1?S.6.SA.Q.tt....At,............... (street and naanx.) as rel.t to KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. .................. . _or ............. . . . . .ba Andover. 5000 gala #5 fuel oil - undgrnd. I C:b or Towel Nate: Th'a rerlifirete of registration mum 6e wttn the hddee of the lirenve if laid liven ar.nmd QQ prior to July 1, 1936,otherte by the o or occupant oft land li Received ......fYF... , ......19...'.... I ...r�/./�//.�r� (Sign t ) by .........J4.HN.. .I ...-. : ONS .. ....LY ............... ........ .......NO: AMOOYERe..ICIf):S-F........................ (Stater weenier relay. command or Inaerl (Official Title) .............................................................................................. • • The (9nmmnn(Itedth of I ziarhusetts Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION N.R.....�tdo wx.........APr11...In.............. 19...64 (City or Tows) Inge) In accordance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned hereby certifies that ........... llr.........Philip....G.WSn.i....................... Address .....-140...kra:Rnott..St....(3hadg..%noll.). �� (Name or nduer of ireaw is the holder of the license granted...Jt1t1B,...9.....1Q,5a...........................''.11.''. 19........for the lawful use of the building(a) or other structure(s) situated or to be situated at...+..Y.O..Pre,soott, St,s................ ist..et and mamma.) a. related tot a KEEPING,STORAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. North kndo .er........................................5.000 gals #5 fuel oil - underground 4city-T.emi Note:This cerdfirne of m6istulioR mmt tNIFt the hdder of the license if mid license was ,ranted prior to July 1, 1936,mherwi.e by the own or or a,,- of t(h�/rY}n�d 1 /i�,�y6 C Received ..................................................19........ .......7''.....L..M.. i.? %........ .tar by .......................................................................... JJJ isim !) .............................................................................................. ................................................................................ iat.te weenie.awaer, ..e.n.m a.tRiaer) (Oaklal Titlel .......................................... .............................................. I AEMidrdaeul • • GyJa � The (9=ntotl[uz9th of .6ttssttcl hafts Department of Public Safety—Division of PSre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION _No.,,_And over April. O 1963... 19........ w'a.r row.) tam In accordance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned It reby certifies that hivlip.......arini........................................... Address .....1LQ._PQA-9..R.Y�.C...St.n...�.51?.tid3...KX?.Q�.�,�.. .... ...... f ;7eolcen of liras is the holder of the license granted........... ....................... ,, 19........for the lawful use of the building(a) or other structure(a) situated or to be situated at.... l4.._Pzoi. .ott._S,t................. .1 ''n� ��q (ft...d .udew) ej000 &e;;� �)6eYC��PIAG�TORAT:EA�SVAGIVRE OR SALE OF INFLAMMABLES OR EXPLOSIVES. .................N.9F.trk1...AT1C1.RXdx........................................ ICib or Town' Note: Thi.mtiaeme of regivn)ion molt he.isned a kidder of)he licen.e if ri wu pored ..'prior to lull 1, 1936,o)h..r 61 a own .' 'p.m of) red li Received ...... . 3......................19.��.:}... ... ....... ...... ..... .............. ......... 11.�il/..(..f..(....... JV OHN J. LYONS by ........................TOW7V"CILERK................... .............................................................................................. NO. ANDOVER. MASS. lauu.enar.wee..«e.o...o.honer) ................................................................................ (OM0.1 TWO ..................................................................................:........... (AM—) JgI27 the Twumutvexlth of Issacltusetts Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION .North..Andavor.........Kay.....24.......... 19...(2 may or Town) (Date) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that I3r.,_Ph111P....Cy.ARX1.RI ARX141..................... Address ......340..P.ae80Att...St... (. a.7...Kxlo11. ............ . 1 Nome.1 holdir of Ileense) is the holder of the license granted.............'T.?�..9.1...�9J.8....................... .......19........for the lawful use of the building(a) or other structure(a) situated or to be situated at.....�Q...Ps..a.BAotet-st.............. 5000 gals #5 fuel oil — IFE�H RA IaveS ORand EXPLl lured to the KEEPING,STORA E, E OR SALE OF INFLAMMABLES OR EXPLOSIVES. ............Ncr.th-And.axer........................................... (city or Town) Note:This tertiarute of mairtr.tion must he dm the holder of th.Brenre if said Homes was sranted prior to July 1, 1936,othervis.by t roe up.m of th td li Received .... ... . ........:.....f.'S................19.�1.. . ......... ....... J N J. ... NS isison. by ..................TQW.N...( F ........................ NO. ANDOVER. MASS. .............................................................................................. ................................................................................ 18ute whether oweer.:e.v.nt or poWerl (OMeW Till.) .............................................................................................. (.Nresl 0 the aintmcozlfuett4 of fflmouhusef#s . Department of Public Safety—Division of Fire Prevention 1018 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION North Andover.......... Pril...S.r....12419........ ........................iciur o:T—.) toeoi In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that .............._Dr:...) 44P..._Guarani .......... Address . 45)...Pr6Aq..0t..gts......................................... iat a of nwaer er arrant . 18........for the lawful use is the holder of the license granted......June..., 4..... . . ... .. .. . ..................... of the building a) or other structure(a) situated or to be situated at........ ��n C.�t 1!.•.St.a,,...,,,,, 5000 gals #`J fuel oil - under round ee relined to the KEEPING,STORAGE,MA FAGFURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. Sklady..Yin.oll..A.est...Holne.,..Paa....Andouer. Ica. Tnnm Note: Thie certificate Of reeievotbn mart be ei th by the holder of the limes to rdd I . wu punted prior to July 1, 1936,otherwise by the r upanl ofJly loe7li��tt�sgdfl ` ...... ..... ....../Y../%.�.•.•..(..-\.A/..�aN..f�lu:.....:..:.'•.. 19 ..... J Received ........ ......�..1.... .. iaienem.et JOHN J. LYONS.................... by ................... . . ............................... YZSWN...CC'E'FYfC.... . .............................. .........•••...•••._leute v6eaw,owne..«eawnt or blaert ...................N.O...AI:IR.QVT R_MP.S.`a:................... " the a mlrmouluettlt4 d tssachu"flo Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION 7G Y7 N9.e..And oPe X .e...........UT......................... 19�.Q... (car or*.w.) (Dtld In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that As......$ 11R 1 ............... Address ... St ........................................ IN,,.nl license gran is the holder of the license Granted......JuI18....9a...1Q5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19........for the lawful use of the building(s) toyr�otherr structure(s) situated or to be situated at.....14JQ...PreA0Ae1�t...S.t•.............. 5000 gal sd#5 fJYE IIVG ORAZE.76A1'tf1FALTORE OR SALE OF INFLAMMABLES OR EXPLOSIVES. ..Shad3.-jec?f?!.4.11..R@.4.t..IIAA1.e.......Naa..Aadavar. City ur T—) Note: This certificate of rcdetration must be aim the holder of the license if said lieenee area scented Prior 1.July 1, 19sf.,otherwise by the of oeeuwnt(p/f�he la need.. Received ........ N&.Y................................19b0... ..�.... ....J7.'.:.......... .:..•........................ JOHN J. t,Nrw NS 31 by �..................T4DW44 fa t&K.............. ........... ...0.... .. ... NO. ANDOVER, MASS. ease s. n..tmmtae.l iZ�'G(Y!�' la q ................................tiffic ......................................... (o Title) IAde:avl • r qe ammonfumit4 RE Rmonhuafts Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION ,North Andover...........May....7................. 19.59.. ofur or Too-) IGtrI In accordance with the provisions of Chapter 148, Section 13,of the General Laws, the undersigned hereby certifies that ...Dr. Philip...C.._Guarin 1...................... Address 1.4.9.. :4.d.4.A. .Ti..$.ri....... A.s..,AA.dG.Y.BS.,t..... INena of EWJte of Ilgnpl is the holder of the license granted..... ......................................19........for the lawful use l of the building(a) or other structure(a) situated or to be situated at......14,0...pme'3A.R.tL.. t.... ........ 5000 gals (' R. K1Jj; ji - underground Isneet as!a®eert C�3hafl -ISnoll u rc red o e K N RAGE,MANUFACTURE OR SALE OF INFLAMMABLES OR EXPLOSIVES. .............................o tAn.do.4.?.?i.x........................................ ICit,or To-.) Note; This certificate of registretion must be rianed by the holder of the licetue if mid Jims ee wse prested Prior to Jul, 1, 1936,otherwise by t e or upset of a Is joressed. a - Received ......MaS...... .&......19.5.9..........19........ ti...:� :.. a,�.�G.Y..�:� .................... by ..............JOHN J. LYONS -TOWN... E M'...................... .,L 1.......1�.................. .....k`..:`:Y.......................................... .....................1`1o...A��t)JZu.�R...1tt�Mr.�.................. I mr.oew tee MI40 loarnl Tusel •IAmrrt • 'ghE (9Dllp1wnfttes4 of cMnwcl nf#s Department of Public Safety—Division of Fire Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION No.,..andoyer.r.........June 191.............. 19.I1 1My or T-1 (note) In accordance with the provisions of Chapter 148, Section 13, of the General Laws,the undersigned hereby certifies that......_Dr....Phil1P...9r...Gusrinit................ Address ....7.j0...Precot ...S...t........................................ (N.— of sold- of am..w sane 9 1958 is the holder of the license granted.........................A...................................... . 19........for a lawful use of the building(s) or other structure(s) situated or to be situated at..,L ..Pre,soott „t................... .and ...rO (sn..e e.a Damn..) an related to the KEEPING, STORAGE, MANUFACTURE OR BALE OF INFLAMMABLES OR EXPLOSIVES. ............North A.rd_overa.. Mass............................ (Cats or Tegi Noll:This certificate of my registration thmust r is signed tl 6y the holder p the f license if laid Red. was granted prior t4 July 1,1998,otherwise by [Hawser or occupant of the land licensed. 1— a 1 8 ..�c ..`.=..t�Cctt.P. :�a�.:4-............ by ..... ............................. .......95...........19........ .. .. xc. �! by ...... . . . ..... ....................... 1 (91 ee wnrtner u..vm. mun.nt or notan) TANDOV R, HAS) �O.�I � � Q.16 .. .. ^ 2 � ail. NO. ANDOVER, MASS. ._.... . . . ... .. �L..... . . ✓L4`/klQ........... ....... LA�J7 (Addrew) /ai.1.P.2 35v 6-53-909930 � _ (�! IjP �AritlliUIiU1PMIf�( n.IyRdSSNthitSPfx6 DEPARTMENT OF PUBLIC SAFETY—DIVISION OF FIRE PREVENTION 1010 COMMONWEALTH AVENUE. BOSTON ( I�OF�M V )own T e v 16n 93� (piy or awn (DLL.)JT APPLICATION FOR LICENSE For the lawful use of the herein described building_.. or other structure...., application is hereby made in accord- ante with the provisions of Chapter 148 of the General Laws, fora license to use the land on which such building.... or other structure__ is/are or is/are to be situated, and only to such extent as shown on plot plan which is Sled with and made a l part of this application /y s e. f(. t . .. ... t..�..... . . . /.'.. . . R . .. 11 Location of Iand }7ll 0 YQ U f //N�mrert trees street `7 c Z,, -Q Y Ca c� �1 Owner of land .k__t ( 1_ I n eil d�".I.1.4 H Address ..../!TKO 1 1"_�.5.C !! � ..`.f..�. u Number of buildings or other arrestor on to which this application applies... N R n.t Occupancy or use of such buiIdinga......_ .._................ . ........... . Total capacity of tanks in gallons.—,�Jbo�g .W111 .._. .... Undeeground `'S..�� . . .... Kind of fluid to be stored in tanks IV .........S�q. Ir"' ..... . ........... ....,._._.. �(�yp.._.... . . ..... APProved—B�pplEOed . ...�.../ _...19 S4 ....�.. . •' Yr'�S.tQ ...._�'� ... . Y/l .a.e or enru t) ....... o re SG.d.Yf S� (Heal or F�m DePW (Addaex) (___________________________________________________________________. NON;' ComPl Prof fans and forward both sections an authdnty (City or C1erk�. Oo not make applicadan to de a to local licensing ` P ent of Public Safety. City or Town NORTHER Oat, 2fd/'/r� APPLICATION FOR CERTIFICATE OF REGISTRATION In a=rcancs mth the provisions of Chapter 1 a6, Secbcn 13, of the General Laws, the undersigned hereby certifies that PRESCOTT HOUSE mm.unea..aeao. REST .eam is the holder of license granted o/r>/a l for me lawful use of the budding(s)or omer strutture(s)situated or to be situated at SCOTT STREET as related to the KEEPING,ING, STORAGE. MANUFACTURE OR SAL OF FLAMMAELES OR L IXP OSIVES. Note-' This applic ldon for card6cere of regismanon must oe s n ig ed by me holder of me g ficansa if said license was ranted prior to Juty 1, 1A36, omerwue by me owner or o¢upent o/me lan sad. Submitted by Recarvao_ �i�f.> o?l o?dO G� - by �9iim ,( ��7Z STE DIiN r�A✓F, +wN. - \\ ra,,. / FDA¢ GiNeSI.{ Hc9LnyCyRe�tlQ�PN17eN (gJN¢2) am r,.. _t4d �Q¢5(p?c$I-i lforC�; :Atic'-�SJc� MA OIQ45 VIP The Commonwealth ofMassachusetts Department oflndustrial Accidents 600 Washington Street Boston,Mass. 02111 .L Workers' Com ensation Insurance Affidavit-General Businesses U/iii•�of rs^�rioiioi• .w�p'".OHO " m o�/�� 1,11M i �oiui ,,,It i /�REf�'e77 [-{ctnE Na,est�ly f�dee TALC. address- /fh� OQFf Corr .STREET .i" , 0A4 state: / zip, 01e1/5 ohonop 1�/ 76)"5 -508G work site Jxation(full eddfessh c 2gm di- 4"A' ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment Unit in any capacity. ❑ice Q Sales(incl cling 1 Estat Africa etc) I am an em to a with^'14`S em to F ll &pa.time). 0�13 ' btu e -Sc.<✓tcc 51C'965%) 9 I am an employer providing workers' comp®sation for my employees working on this job. S� as f{lod.IC IF address: / imuraoee eo. L+het"-I lyJiJAI rtRv' tiil.i�'Rl.i.F Co. li M I am a sole proprietor and have hned the indep®deot wntractors listed below who have the following workers' compensation polices: address: n. ohoue#• insure.''ea. lie # y m address „ ohoue#: insurance ca. tic # onaure m seuure mvenge as required under Section SA of MGL I O can lead to the Imp nd a f face crledam 0 a day a sin Doe, to g130a.nd eadtor ooe yarn Vmprao.mem as well ne dve to tha s m the form of g STOP WORK ORDER end efma ofati.n. a a day agviwt me. I uadenmed that copy of ihb statement may h fomarded to the Olfiee of Iuveadgatlam.(the DIA for'avenge veralaa9on ldohee.byof /Qq the sand penalties ofperjury thin the information provided above is Or/yy�tt and rorrert Siva ..�aL �-'u-'�• Date 'q o" Prim name • S' t lr♦EnldiS Phone# Official we arty do an,orne in thb am to he completed by aty or town talucal ctyortenn: peradblaemep 0Bailding Departuuut EILiaemmg Board ❑aheakalmmedute reapome b required ❑Saketeroa's Omae [111n1th Department '..tact person: phone#; 1]Other (mkae�20]il Note: Ccmpler p W form and forward both sec5ona and, �to lacal licensing authority (City or n Clerk). 0, not make application to de PP em of Public Safety. �o�rruirtootcuea�l2 a�i2//%�aaaaclivaeGlt Je�ha�CinenCo��'vKeVrlweies — J.'vweco�ie o��rvKe ✓",.�umteon Cltyar Town NORTH ANDOVER pat,APR/=ai3 APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 148. Section 13, of the General laws, the undersigned hereby certifies that PRESCOTT HOUSE .wm.a.aora�v EET nm... is Me holder of license granted o/t 2�g�for me lawful use al the budding(s)or other vmaure(s)situaled or to be situated at 13COTT STREET as related to the KEEPING, STORAGE. MANUFACTURE OR SAL OF F!AMMASLS OR EXPLO SIVES. OSIVES. Nore., This appliWbon/or cerrt6gte al regisrraaon must be signed by/he holder or the license/f said license was granted pncr w July 1, 1946, Od?O mse by the owner or=upanr of the d.la o"IIceiT.�e Received r�(�h Z ?� aCYL? Submitted by by 9iY1Jf oC �11 �s✓ eta Nf t /��o�h /,Q p' c'SLdR �^ .�,v�., Nate: Compie op of form and forward both sections an to local licensing aLrtf (City or Tdwn Clerk). 00 not make application to department of Public Safety. j � -, lOf/IYI/I77.6'IZC(CJ2p�L�y /Li!C:�/l/�CCdQCLCJ7,L�1��%y � �e�ca"Gnre�eG'o��ir'riwe Fliawecay —_/�' ?� rnxocooe o��in e :l-reventcnn City or Town NORTH ANppOVEg O/f// o7(f7d APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 1<6, Section 13. of the Generaf Laws, Me undersigned hereby certifies that PRESCOTT HOUSE EET eyv. ¢the holder Of license granted o/t tq for the lawful use of the building(s) or Omer stNCure(s)"Weep or Io oe squared at PilESCOTT STREET as related to Me KE?ING,STORAGE. MANUFACTURE OR SALE OF FLAMMABLES OR EXR!OSIVES. rw d Nore: Thu applioavon for cerdfioate or re91st2non must be slgneo by the holder of me Gcanse if said license was Slanted prior ra Jury 1, 1936, otherwise by me owner or oc�pant of me l4odtcapsed. Received-LLl�/// 5 Oya i aT SuomiRed by by -��it .1�. fM adtie f, r 14 a IZ/ &R ,Or/,X RA19 Ot9Y5 Note: Compote tf form and forward both sections and feJ Iopl licensing authority(C1Fj or Town�Cjlerk), Do not make a/ppllication to department of Pudl'c Safety. y —��/e�ianrGneerrCo��iixe Cc/itwicm — �ywyr� o��vrs ✓"xeuenCean City or Town —NORTH ANDOVER Date 2c,t?c3et�'gg/ APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the prwsions of Chapter 146, Section 13, of the General Laws, the undersigned hereby cenifies that PRESCOTT HOUSE .s.,,.rmnrrea,„ EET is the holder of license granted 0/1 7�R�_for the lawful use of the buiiding(s)or other structure(s)situate,or to be situated at 140 PRESCOTT STREET as related to the KEEPING, STORAGE, MANUFACTURE OR SAL OF FLAMMABLES OF EXPLOSIVES. r Noe: This 2M#=rion for certificate at registration must be signed by the holder at the license if said license was -/ —grraanted prior to July 1, 1936, otherwise by the owner or occupant of the]an nse . Pece^'ed---__(%r/dC/�t ��i700Y/ Submitted by by „d,y, kLoR? yArrSf nl /�NY✓seM/}ofgy� Note: Complete to form and forward bath sections and fee local I`1!f 7�afng authority (City or Town Clerk). 00 not make applicrticn to department of public Safety. �; !7t � zusea� c�� /r�aaaczc�ivae� ��f�xL.ncmt a�ZCGtiFe FSi>wicm_ '�i vwaare gr°�iire �✓' an City or-,o.n _NORTH ANOOVER Date -W ol, APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 148. Secd" 13,of the General Laws.the undersigned hereby candies that PRESCOTT HOUSE 140 PRESCOTT STREET me is Na holder of license granted l o,t �A I for the lawfu use of the building(s)o.v g(s)or oNer strucmre(s)situated or to be situated at 140 PRESCOTT STREET as related to the Ke=IING. STORAGE. MANUFACTURE OR SAL OF FiAMMASL_S CR E(p.' OSNES. c r NOre: This application for cardficat4 of mgistravcn must be signed by the der hol of the granted pdor:p July 1. 106, otherwise by the owner or prapant o1 Me/and l se, Eense was 6 Received a / a�eoo C am SubmMed by by x c 0 ,ems,,.. frst IBN�a,tze Note: Complete�°f form and forward both sections and f local licensing authority (City or Tri�Clerk). Do not make application tc depa ent of Public Safety. �amirnaru�e 11 c,l�tq? cge -10-4 1 d o z o�9 re ✓ a t City or Town NORTH ANDOVER Dare_ APRIL 3y99 APPLICATION FOR CERTIFICATE OF REGISTRATION In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that A (PRESCOTT �) Nous� GGq[JiJ E/p(,rtip.e (av , wwarrwa.wa.» 140 PRESCOTT STREET is the holder of license granted SEPTEPBER 3;-, 1981 for the lawful use of the building(s)or other structures)situated or to be situated at 14n ➢RFCPOTT STRFFT as related to the KEEPING,STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. NORTH ANDOVER carom ra., Note: This appticafton forcerdficate of registration must be signed by the holder of Me license d said license was granted pdar to July 1, 1936, Otherwise by the owner or=upant at the land licensed Received ��nT,o_ �� ir�99 Submitted by V, CA �,� /4h �i'vc,<r !i ,rJi Anav4i rstA+,u stry -- wAIIaAIIIIIR �eewrr_ ....�... -- Note: Complete tarn and forward both sections and to local lamming authority (City or T�erk} Do not make application to depar�rrft of public Safety. n � I� tQtYrI7/l7'WiI7iL/18QA�i2 O�v//�CLQQpC/LC��. ,mot p c� o/�'iire :lw�urinGan Cltyor Town NORTH ANDOVER OateAPRIL 30, 1998 APPLICATION FOR CERTIFICATE OF REGISTRATION In aocrdance with the provisions of Chapter 146. Sectian 13, of the Genemi Laws, the undersigned hereby certifies that ALAN 0. SOLOMONT (PRESCOTT NUSRING HOME) 140 PRESCOTT STREET e.m.en�d .emw is the holder of license granted SEPTEMBER 17 1981 n for the lawful use of the building(s)or other stri caure(s)situated or to be satiated at 140 PRESCOTT STREET so.e,mm.�o. as related to the KEEPING, STORAGE, MANUFACTURE OR SAL OF FLAMMABL_S OR EXPLOSIVES. NORTH ANDOVER Grra„ Note: This application for camffcate of mgwmnm must be signed by the holder of the license N said license was granted prior to July 1, 1936, 0010mse by the owner or oc ipant of the lend licensed. Received esub� z/' �aq, 199Z Submitted by . by �E(LQ7Ld_- rL. L.rJ t'7L 160 PRE-E-01T CTRFFT NORTH ANnOVPR NA anta�ra. NOTE: COMPLETE TO�ND BOTTOM OF FORM AND FORD BOTH SECTIONS AND FEE TO AL LICENSING AUTHORITY (CI R TOWN CLERK). DO NOT RETURN FORM TO DEPARTMENT OF PUBLIC SAFETY. ti Department of Public Safety—Division of lire Prevention ev CERTIFICATE OF REGISTRATION ..NORTJI.dNOOIIE&....................ARRdL..30T-....... 19....az ICI,w Teel IDuvl_ In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ALAN 0.,SOLOMO)1T,,,(g SGQxI'„}jRUSE4......... Address .....140..PRESCOIT..aT.REET.,..AIORSH..ANDOYE&,..IIA INvme of pWw W lieenul is the holder of the license granted......................... ......................19....81for the lawful use of the building(a) or other structure(s) situated or to be situated at....1.4A..ERESJMT.1..5a8EEI............... p �J.� leuue "' a""W" li'j NOVANDOVoERe KEEPING,STORAGE,MANUFACTURE OR SALE OF FLAMMARLES OR EXPLOSIVES, .................r...................................................................... Icily ee Torn I Note: This c"tifieete of eesistmtion must he used Is,the hold"of the nemse if mid Reese ve a nmd Psi. to July 1. 1936.whe—iee by the or or "at of the levd Iicen, Received . April.:l5 . ..............................19..97.. .. e .. ... .......by ....................................... s mstont Judith E. Elinn .......................................................................... ALAN 0. SOLOMONT (PRESCOTT HO H. Executive Director ..................................... seu................................................. ................................................................................ tmep+h.Wr wne.. weepevt n heN..t to61eW stet 140 PRESCOTT STREET, NORTH ANDOVER, MA 01845 .............................._.............................................................. (Am.) NOTE: COMPLETE TOP ANWOTTOM OF FORM AND FORW BOTH SECTIONS AND. FEE TO LOCAIIWCENSING AUTHORITY (CITY TOWN CLERK). DO NOT RETURN FORM TO DEPARTMENT OF PUBLI SAFETY. The ( tImmmffiralth of Assadjusetts. lugDepaJ'tment of Public Safety—Division of Are Prevention 1010 COMMONWEALTH AVE., BOSTON CERTIFICATE OF REGISTRATION NORTH...ANDOVER........ ... 19._82. . IC14 or To-n( - (P4) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ....IUaa.O...Solcacnt_�..1'3'A.00QY12...A.4use).... Address .....ILO Ps+aecott St. . . ......................................................... f th license ]NOV—)ran Sept. l7a 1981 is the holder the license granted............................................................... .. 79........for the lawful use of the build?(s) or other structure(s) situated or to be situated at..1L0 Prep .;m..3yR....................... ¢ �g eddathe KEEPING,�S�TORRAGE,MANUFACTURE OR SALE OF FLAMMABLE$ OR EXPLOSIVES. - ...w�- - f PI-H...A-ND01/ 7H........................... 500 gals. Diesel Fuels Ouiot—� " FF1Ii.rertmr.te or rc i t be.i d try the holder or the lircn.e if wid arcn.e...p.nted ao~c: r pi. a ion mm Rne r '(�y",_/gµ�- prior to Julr I. 1936,otho.i.e by the o • or cnp.m th l.y ryd^i d. ReceRt—s ra t9�.v.mn1 by ..................................................................I........ .............................................................................................. ... (St.te �habr ..vrr, vr.ve.m.r MY.n - Io9iN.t T(tlel ' .............................................................................................. (Mlr.1 NOTE: COMPLETE TOP AS BOTTOM OF FORM AND FORD BOTH SECTIONS AND FEE TO LOCALLICENSING AUTHORITY (CIT TOWN CLERK). DO NOT RETURN FORM TO DEPARTMENT OF PUBLIC SAFETY. Tht (9 mm m(UtAth of fflassuchusetts Department of Public Safety—Division of Mre Prevention 1010 COMMONWEALTH AVE., BOSTON i CERTIFICATE OF REGISTRATION NO..RTR A BOVER._�• .... ........... 19..81. (City or Town) ItL1e) In accordance with the provisions of Chapter 148, Section 13, of the General Laws, the undersigned hereby certifies that ALn.O..&t1a�mL L..T✓ �RQpLA../WN).... Address ..... ............................ 17 is the holder of the license granted...........................:t..................................,.`�.,.., ..19........for the lawful use of the building(s) or other structure(s) situated or to be situated at...*..P"49f it._tea....................... (a".and mm�sort as rela ed to the KEEPING STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES. NRT A��b�IER........................... 5W DISMI Anl' Note: This rertlfiride of reai.oation tou.t be dared 1h".1de,of the liceme if.aid license was Granted 7) p/yf'oyp July 1, 1936,mherwi.e by the o e oecupan of th d 1'ee=Psnt� d Rec,"*..ft�.................................` :......19........ ... ...... ... ..... 1 ^..p .. .....by ......WU3S�11 .................. O l.......................................... ........... .. .. ..... ...................9NoT]7T�f3g1N}�va .. 7dia: ..r..n 6�ATi"31 1, Tak)............................... ........ .................................................................................... taddr.1 I.-". w-,",-wo. 004t Tommonmrsltll of filtssttrlin rtts = DEPARTMENT OF PUBLIC SAFETY—DIVISION OF FIRE PREVENTION 1010 COMMONWEALTH AVENUE. BOSTON Arla, L444,7o/e1- n 19 y(m or Taw ) fa u) APPLICATION FOR LICENSE For the lawful use of the herein described building... or other structure,..., application is hereby made in accord- ance with the provisions of Chapter 148 of the General Lows, for a license to use the land on which each building._. or other structure.... is/are or is/are to he situated, and only to such extent as shown on plot plan which is fled with and made a part of this application. Location of land.l YO 1f<S.C.o11 ..... . .. ....Nearest arms fftmet... zas........ Q s x qsa ) Owner of land._._F r�pn ... ._...Addrma .........L!{f2..........r.?,$,.6. 2.7. �..._s .......................... Number of buildings or other structures to which this application applies................. ..Q.h!.L'... Occupancy or use of such buildings.......43D.....6- J..n").µ.ftSL.Nf� A!.:!..t ..................... ................... j Total capacity of tanks in gallons:—Above{ground_... ...._. fl ..... . ... ...... .Underground ...6. OQ..�.GuLS................ Kind of fluid to be stored in tanks.............iJ.i2.S.2. .......'.,'45.5'._L............ ...I............................... .... ._..... ..........._...... � '7 p ,y//q .. ........... 'A — leappror2d ._ SAY L......._�..(..... 1BV/............ .O.,hws-,,.. ... ...r?� ...... .. mw.le m .rwl,.an ... ....... . . . ............. .....L......... .................... .............__. .................. (Head of Fire Dept.) (Add.) L4r Tommonwralt4 of Massttrlpcsrtts DEPARTMENT OF PUBLIC SAFETY—DIVISION OF FIRE PREVENTION 1010 COMMONWEAL(�YwIL 'Fl"ANT{1OVEF 11''����������SSfd �� 'rFFY111 (clg)UUo�lr Towv) (bald 1.9 LICENSE In accordance with the provisions of Chapter 148 of the General Laws, a license is hereby granted to use the land herein described for the lawful use of the building.... or other structure__ which is/are or is/are to be situated thereon, and as described on the plot plan filed with the application for this license. Location of land,l"<�. �a�. �.:?CgU.x ... . ...Nearest cross street . ..1z /Z S— Owner of land AI' VA(... . ......Address Number of buildings or other structures to which this license applies 644 N._) ... Occupancy or his of such buildings Total capacity of tanks in gallons:—AAb^b�ooveground. �...... .._.Underground faU �S Kind of fluid to be stored in tanks .._yL,CSC.. .f......�1 .. ............................................................................................. Restrictions—If day: ........................ .... �(6 gvalure of eeevewg avW dy) THIS LICENSE OR A PHOTOSTATIC OR CERTIFIED COPY THERE F MUST BE CONSPICUOUSLY POSTED IN A PROTECTED PLACE ON THE LAND FOR WHICH IT IS GRANTED °% F�Jer . �lr 70 -� aaer�e �Ll J r��Gi,�fQo � s q Q�E�7,7'".� , �'�a-e 3 Q�,c C� c2o� i / TGIN OF NORTH ANDOPI. NOTICE OF PUBLIC HFAHING Notice is hereby given that the Board of Selectmen, Town of North Andover, Will hold a public hearing on June 9, 1958 at 7:30 P.M. in the Selectmen's Office, Toaw Building, on the application of Philip C. Guarini, M.D., Shady Nursing Horse, 140 Prescott Street, North Andover, for a license under the provisions of Chapter 148 of the General laws to store underground 5,000 gallons of S5 fuel oil at 140 Prescott Street, North Arxiover. BALPH E FffiCK, ®LIBHAN WILIJAM A FIXIMM PHILIP SUTCISFFB BCAO Cr SELECT= Copy of this notice sent to abuttors. List of abuttors attached May 29, 1958 Nay 29, 1958 Tribune Publishing Gompany 285 Lesex Street Iawrence, I;assachusetts Bear Sires kindly publish the following as a legal notice in your nempapere TOWN OP NORTH ANDOV�'R May 30, 1958 Notice in will hold aereby given that the 3oard of Selectman, Town of North Andover, Office Public hearing on June 9, 195a at 7:30 Y.lt. in the Selectmenjs Town Building, on the &pplication of Pbilip C. Guarani, elect, Treasurer Of Shady bnoll hwaing Home, 140 Prescott Street, North Andover, for a license under the provisions of Chapter 8co of the General lave Andover, to Norstoth Andover. 5,00:: 6'allons of ;$ fuel oil at 140 Prescott street, Ralph E. Fihck, Chairman William A. Finneran Philip Sutcliffe BOARD OF ScZ OTH,;;N North Andover.Please send bill for same to Philip Ce Guarini� M.D., 1,40 Prescott Street Nor A copy of this notice would be appreciated. Very truly yours, BOARD CF SEUCTM..i3d Ralph Z. Finck, Chairman Ri,F/� n( 5 lerfm n, Towp ai NOY 9h t la Oa 'J1 holtl Yf omh[And-- M. PhI1p In¢t¢ 5<IeMmen9e' Ottla, Town H CLlne, a a a.oI e�oI Shetiv mr."Ma% Hmneepae�,, 7, rnt[ Stet Narth AnEov¢p ett. ¢ IP8gln1 M.CteNttel Ota[pOf Nefag o1¢e o tl 5. n #tl LYN i et¢3,0 ad tt st ibm nl not Fret Naelh AOdov¢r RILPFE P1NM Chalemanl'w¢LIAM e • ...'a of Se V