The URL can be used to link to this page

Home My WebLink Aboutunerground storage 1-3 mass ave p �+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 30,2022 (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 COB Real Estate LLC (ADDRESS): 1-3 Mass Avenue is the holder of the license granted(Date): 7/29/1985 for the.lawful use of the building(s)'or other structure(s)situated or to be situated at (ADDRESS): 1-3 Mass. Avenue 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. R� Rece' e . 022......... ...... ........ .................... (Signature) By ........ . ...................................................... (Official Title) erk) (State whether owner,occupant or holder) (Address) 01 f'J j w' Department of Fire Services J4 Al Office of the State Fire Marshall. P.O.Box 1025,State Road,Stow,MA 01775 REGISTRATION North Andover, April 30,2022 (City or Town) (Date) This is to certify that COB Real Estate LLC. 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: Merrimack Valrey Oil Co. is the holder of the license granted(Date)7/29/1985 for the lawful use of the building(s)or other structure(s)situated or to be situated at: 1-3 Mass.Avenue as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES 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 '4 CERTIFICATE OF LIABILITY INSURANCE DAT 08/101 08l10/D/YYYY) = 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 tmider is an ADDITIONAL INSURED the poi;yfles) east have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the polity, certain policies may require an endorsement. A statement on this certificate does not confer ri hts to the certificate holder in lieu of such endorsements. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME:N CLIENT CONTACT CENTER HOME OFFICE: P.O.BOX 328 A CNo EXt:888-333-4949 A CFAX No):507446 4664 OWATONNA,MN 55060 ADDRIESS:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 240-099-2 INSURER B: NEWBURYPORT FUELS CORP. INSURERC: 1 MASSACHUSETTS AVE NORTH ANDOVER,MA 01845-3412 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:20 REVISION NUMBER:0 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 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL.SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDDIYYYY MMtDDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE l A I OCCUR DAMAGE TO RENTED PREMISES ce $100,000 ME EXP(Anyone person) EXCLUDED A N N 6076996 08/28/2021 OW28/2022 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 �.Cy ❑JEST [—ILOC PRODUCTS-COMPIOP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 O BODILY X ANY AUTO I n BODILY INJURY(Per person) q OWNED AUTOS ONLY AUTOS N N 6076995 08/28/2021 08/28/2022 BODILY INJURY(Per accident) HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY P-r aridan• X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAB CLAIMS-MADE N N 6076998 08/28/2021 08M12022 AGGREGATE $2,000,000 DED I I RETENTION WORKERS COMPENSATION OTH- AND EMPLOYERS'LIAB Y!N ILITY X PER STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICEWMEMBEREXCLUDED? NIA N 6076997 08/28/2021 08/28/2022 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE MOLDER CANCELLATION 240-099-2 200 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845-2420 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents cn ' Offce of Investigations Lafayette City Center 7 Aven !,- de Lafayette. Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ' Please Print Legibly Business/Organization Name: 116/�?cL.� b6tn, D Address: City/State/Zip: Phone #. Are you an employer? Check the appropriate box: Business Type(required): c<I am a employer with employees (full and/ 5./K�R.etail or part-time).* 6. ❑ Restaurarit/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. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers 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]** I I.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. imurance req.] 12.0 Other *.Any applicant that checks box#1 must also fill out the section tclow showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corps:ation has other employee;,a workers'compensation policy is required and such an organization should check box#1. I am an,,�:,ployer that is providing worker,'. nnpensation insurance for my employees. Below is the policy information. Insurance Company Name: ede,r_led AA L., 1 (4 � -To 44 J 4 c e J Insurer's Address: / C) o�JD City/State/Zip: C;v a T Gn YLaj — z44/1, G� /9 n Policy#or Self-ins. Lie. # t�� / 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 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 pains and penalties of perjury that the information provided above is true and correct. Sign .yature: Date: o /l 0202 Phone#: - Official use only. Do not write in this area,to be completed by city or town of icial. City or Town: Permit/License # Issuing Authority(check one): LE]Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.❑Other Contat:t Person: Phone#: www.mass.gov/dia