HomeMy WebLinkAboutunderground storage Department of Fire Services
`bsbh' �'c 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): Greater Lawrence Sanitary District
(ADDRESS): 240 Charles Street
is the holder of the license granted(Date): 6/21/1976 for the lawful use of the building(s) or other
structure(s)situated or to be situated at (ADDRESS): 240 Charles 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.
Receiv . . . . . ......t.. 22......... ..............
(Signature)
By ... ......... .... ...... .............Holder................................
(Official (Clerk) (State whether owner,occupant or holder)
240 Charles St. North Andover, MA 01845
......................................................
(Address)
4i Department of Fire Services
(R
Office of the State Fire Marshall
�bssah �a P.O.Box 1025,State Road,Stow,MA 01775
REGISTRATION
North Andover, April 30, 2022
(City or Town) (Date)
This is to certify that Greater Lawrence Sanitary District
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: _Greater Lawrence Sanitary District
is the holder of the license granted(Date)6/21/1976
for the lawful use of the building(s)or other structure(s)situated or to be situated at:
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OFF M BLES OR EXPLOSIVES.
........................................
(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 CONSPICUOUSLY POSTED ON THE PREMISES.)
EXPIRES APRIL 30,2023
The Commonwealth of Massachusetts
Department vfIndustrialAccidents
t.
Office of'Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, M4 02111-1750
www w iss.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeLyibly
Business/Organization Name: Greater Lawrence Sanitary District
Address: 240 Charles Street
City/State/Zip: North Andover,MA 01845 _ Phone #: 978-685-1612
Are you an employer? Check the appropriate box: Business Type(required):
i. I art a employer with 40 _employees (full and/ 5. ❑ Retail
C'part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insuranz.:,.required] 8• �] Non-prof t
3.❑ We are a corporation and its olTicers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.j] Health Care
with no employees. [No workers' comp. insurance req.] 12. x❑ Other municipal wastewater plant
*Any applicant that checks box#1 must also fill out the section below showing their workers'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#1.
I am an employer that is providing workers'compensation insurance for m»employees. Below is the policy information.
Insurance Company Name: MEGA
Insurer's Address: 55 Walkers Brook Dr. Suite 402
City/State/Zip: Reading, MA 01867
Policy#or Self-ins. Lic. # X34069 Expiration Date:
Attach a copy of the workers' compensation polic3 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 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 staterr..,-nt may be forwarded to the Office of Investigations of
the DIA for insurance coverage verification.
I do herelw certify nde he pai; nd penal,°ies of per ry that the information provided above is true and correct.
Signature: �� Date: 7//o oR
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
I.❑Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.El Licensing Board
5.❑Selectmen's Office 6.❑Other
Contact Person: - Phone#:
www.mass.gov/dia