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`�! h 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, 2022
(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): Holt Road LLC
(ADDRESS): 210 Holt Road
is the holder of the license granted(Date): 6/30/1997 for the lawful use of the building(s)or other
structure(s)situated or to be situated at (ADDRESS): 210 Holt Road
NORTH ANDOVER, MA 01845
(City or Town)
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAM OSIVES.
NOTE: This certificate of registration must be signed by the holder of the ' se if id li s e p r to July 1,1936,
Otherwise by the owner or occupant of the land licensed.
Re eive ... ..... .:,!.✓..2022......... .. .... ....
Si
(O cia itle) (Clerk) (Sta a whether owner, ccupant or h de)
Av.. �.e1.1 ?...............................
The Commonwealth of Yfassach usetts
Department of IndustrialAccidents
Office of Investigations
t - Lafayette City Center
�. 2Avenue de Lafayette, Boston, AL4 02111-1750
Y
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organza ion Name: 4tr
Address:
City/State/Zip: �0'r_T}} 4- 01M Phone #: 919 69_qu (U
Are you an employer? Check the appropriate -x: Business Type(required):
1.❑ I am a employer with employees (full and/ 5. Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ ?. ::.n a sole proprietor or partnership aizd have no 7. ❑ Office and/or Sales (incl.real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• ❑Non-profit
3.[ ] We are a corporation and its.officers have exercised 9. ❑ Entertainment
�h their right of exemption per"c: 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.j] Other
*Any applicant that checks box#1 must also fill out the section below showing their A orkers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers' compensation policy is required and such an
organization should check box 41.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under § 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 imprisorime w l as civil penalties in the form of a SWOP WORK ORDER and a fine of up to
$250.00 a day against the violator. advise at a copy of this statement may be forwarded to the Office of Investigations of
the DIA for insurance coveraZw.Wrifica '
I do her y certify, r nd ury that the information provided above is true and correct.
SigLiatur_;. Date: C404 al),92
Phone
Official use only. Do nof write i:i z'zis area,to be completed by city or town official.
City or Town: Permit/Li.cense #
Issuing Authority(check one):
1011oard of Health 2.0 Building Department 3.0 City/Town Clerk 4.El Licensing Board
5.❑Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.mass.gov/dia