HomeMy WebLinkAboutUntitled h' ih1 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, 2023
(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): Merrimac Condominium Trust.
(ADDRESS): --- -89.-Main-St-Merrimac M A 01810
is the holder of the license granted(Date): I 1-07-2022 for the lawful use of the building(s)or other
structure(s) situated or to be situated at (ADDRESS): 4-100 Compass Point
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 sai icen a was granted prior to July 1,1936,
Otherwise by the owner or occupant of the land licensed. 6,Q00 g S
Recei `,1�.�! &G 3.........
(Signature)
By .............. }MGtia ...
(O 1 (Clerk) ( tate whether owner,occupant or holder)
(Address)
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investigations
Lafayette City Center
2Avenue de Lafayette,.Boston, MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:. /1 T-Pvf,IV"G C CS�—
Address: CpAr\,P s<,
City/State/Zip: P(9f- A A,\- o,r�j WV 1A— 01 N r Phone #: ° -7 -3 bo k o y3
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I.am a employer with employees (full and/ 5. ❑ Retail
_or part-time).* 6. -❑ Restaurant/Ban/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]**
4. sl We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.[3 Other �,�,�� ���,V:-LM l�5 b(i17;,7—
*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 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 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 insur coverage verification.
I do hereby c tify, nder the pai and penalties ofperjury that the information provided above is true and correct.
SigLiature: Date: 3 a�
Phone#: g03 h l coo
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):
10Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.El Licensing Board
5.❑Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.mass.gov/dia