HomeMy WebLinkAboutUntitled ba, ,ar 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): Elm Square Condominiums
(ADDRESS): 1980 Turnpike St
North Andover MA 01845
is the holder of the license granted (Date): 11/08/2023 for the lawful use of the building(s) or other
structure(s) situated or to be situated at (ADDRESS): 1980 Turnpike St 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. 700 g propane
Recei e �M.1 1 ��Y..l. 23......... ................... ..........
B `5� ,,1,,,,, ..................(Signature)
y (Offici itl ) (Clerk) (State whether owner,occupant or holder)
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.... ..................:...F. G'liu Y.Sr
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'(City or Town)
(Date)
-NOTE: Complete-top and•bottom of form and forward both sections.and fee to local,Licensing.Authori.ty(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'ceriifies that:
(TITLE HOLDER):Elm-Square Condominiums
(ADDRESS): I*Turnpike St
Norih Andover MA 01845-
is,1he holddr of*the licen's6 granted(Date): 11/08/202:1 for the lawfufuse 6f.the buildirig(s)or other'
structure(s) situate'd or to be situated at (ADDRESS): 1980 Turnpike St NORTH ANDOVER, NIA 01845
(City or TownI 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. 7000 gals propane
Received ...........................2021......... ...............
(Signature)
By ........................................ .......................................................
(Official Title) (Clerk) (State whether owner,occupant or holder)
......................................................
(Address)
Department of Fire Services
(�� a`� Office of the State Fire Marshall
P.O.Box 1025,State Road,Stow,MA 01775
REGISTRATION
North Andover, November 8, 2021
(City or Town) (Date)
This is to certify that Elm Square Condominiums,
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: Elm Square Condominium.
is the holder of the license granted(Date) 11/0 8/2021
for the lawful use of the building(s)or other structure(s)situated or to be situated at: 198O Turnpike St
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES, OR EXPLOSIVES.
7,000 gals propane
(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 PRENHSES.)
EXPIRES APRIL 30,2022
Note:Complete top of form and forward both sections and fee to local licensing
authority(City or Town Clerk). Do not make application to department of Public Safety.
�efuriJ�7ne�cta� �'rixe��i�uia�.s— �rirfi�a�c o�-T''i�xe ✓-a��r,�'aiz
City orTown 6—V40_0�Y( Date !3
APPLICATION FOR CERTIFICATE OF REGISTRATION
In accordance with the provislons of Chapter 148, Section 13,of the General Laws,the.undersigned hereby certifies that
Co�4o�rfJ<uwlS
Aftmws
r` wn.a bordrrauo�rssa
is the holder of license granted for the lawful use of the building(s)or other structure(s)situated or
Due
to be situated at /9l�'v %yi'1N1�l Kt=
Str«r�ncnu»ar
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
1. rcn-f ���vo0V(l— t
• Crryar ro.r
Note:This apprrcatlon for 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 a Jand licensed.
Received Submitted b <—"
oar► Sown"
by .Vic•t=yC.
rtamrr Sum WW"ro e.r,000" arr,m.r
City or Town Date
REGISTRATION
This is to certify that
LftW WOW
has,in accordance with the pfcvisions otChapter 148, Section 13, of the General Laws,filed with me a certffificate of registration setting
forth that is the holder of the license granted
for the lawful use of the bulding(s)or other structure(s)situated or
Dam
to be situated at
So�arar+drrum.r ,�
as related to the KEEPING,STORAGE,MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
. sou w and chwir new
Note:A caffiffcare o1 most ufm must be 61ed an or before April"of each yaw.
THIS REGISTRATION MUST BE CONSPIVOUSLY POSTED ON THE PREMISES
FP-5(reviW W".
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GIS Coordinates
/✓(�i�T/'l AvR'1pyex ,
License
t` LONO.
Massachusetts General Law, Chapter 148 §13
FP-2 Uo=cN=bcr
(Rev.os_2m) ❑New License .0 Amended License
After notice and hearing,and in accordance wish Chapter 148 ofthe Mass.General laws,
a license is hereby granted to use the land herein described for the purposes described.
Location of Land: My 1 r'� 14l):�t
�,3'`cea uesor� /gym use
Owner df Land:_ eFLtAA ®U Lr✓ CO�Y40 v� l N/yrtit$
Address ofLandOwner: TyK4//f1<1C— S� �. /c �'Jt��y r A4,4
Flammable and Combustible Liquids,Flammable Gases and Solids
Complete this section jor the storage offlammable and combustible liquids,solids,and gases.All tanks and containers are
considered full for the purposes of licensing and permitting,(Attach additional pages if necessary.)
PRODUCT NAME CLASS MAXI1 WX UNITS CONTAINER
QUANTITY gat.,lbs, UST,AST,IBC,
cubic feet drums
�179AN�� 7�D �,�cc�S A�
LP-gas(Complete this.section jor the storage of LP gas or propane)
❖ Maximum quantity(in gallons)of LP-gas to be stored in aboveground containers:. 7 C
List sizes and capacities of all aboveground containers used for storage
4S Maximum quantity(in gallons)of LP-gas to be stored in underground containers: ! _
List sizes and capacities of all underground containers used for storage
Total aggregate quantity of all LP-gas to be stored: 7 0
Fireworks (Complete this section jor the storage of fireworks)
ireworks)
❖ Maximum amount(in pounds)of Class 1.3G:
Maximum amount(in pounds)of Class IAG:
%% Maximum amount(in pounds)of Class 1.4:
Total aggregate quantity of all classes of fireworks to be stored:
THIS LICENSE ORA CERTIFIED COPY THEREOF MUST BE CONSPICIOUSLY
POSTED ON THE LAND FOR WHICH IT IS GRANTED.
Explosives (Complete this section for the storage of explosives)
Maximum amount(in pounds)of Class 1.1: Number of magazines used for storage:
Maximum amount{in pounds)of Class 1.2: Number of magazines used for storage:
Maximum amount(in pounds)of Class 1.3: Number of magazines used for storage:
❖ Maximum amount(in pounds)of Class 1.4: Number of magazines used for storage:
Maximum amount(in pounds) of Class 1.5: Number of magazines used for storage:
Maximum amount(in pounds) of Class 1.6: Number of magazines used for storage:
Licensing Authority Use: ;
This license is granted upon the condition that the licensed activity will comply with all applicable laws, codes,
rifles and regulations, including but not limited to Massachusetts General Law, Chapter 148, and the
Massachusetts Fire Code (527 CMR 1.00) as amended. The license holder may not store materials in an,amount
exceeding the capacities herein specified unless and until any amended license has been granted.
ADDITIONAL RESTRICTIONS:
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ib icensing Authority Title Date `
THIS LICENSE OR A CERTIFIED COPY THEREOF MUST BE CONS)PICIOUSLY
POSTED ON THE LAND FOR WHICH IT IS GRANTED.
FP-002(Rev. l.1:2015) Page 2
Town of North Andover, MA September 17,2021
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MAP FOR REFERENCE ONLY
NOT A LEGAL DOCUMENT
Town of North Andover,MA makes no claim and no
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Geometry updated 4t 2021
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AdutiertoAbutfer( X) BulldingDept. ( ) Conservation( ) Zoning ( )
TOWN OF NORTH ANDOVER
ABUTTER LIST
REQUIREMENT: MGL 40A,Section 11 stales In part"Parties In Interest as used In this chapter shall mean the petitioner,
abutters,owners of land directly opposite on any public or private way,and abutters to abutters within
three hundred(300)feet of the property line of the petlitioner as they appoar on the most recent applicable
tax list,not withstanding that the land of any such owner Is located In another city or town,the planning
board of the city or town,and the planning board of every abutting city or town."
SUBJECTID LOCATION OWNER ADDRESS CITY STATE ZIP
106.D00017.0000,0 1980 TURNPIKE STREET ELM SQUAREINDISTRIAL CONDO'S 1980 TURNPIKE STREET NORTHANDOVER MA 01845
PARCELID LOCATION OWNER ADDRESS CITY STATE ZIP
106,D-0032-0000.0 BERRYSTREET PADELLARO,BETH M 8 MICHAEL 193 BERRY STREET NORTH ANDOVER MA 01845
108.0-0049-0000.0 193 BERRY STREET PADELLARO,BETH M 193 BERRY STREET NORTH ANDOVER MA 01845
106,D-0053.0000.0 213 BERRY STREET GOODWIN,LORI 213 BERRY STREET NORTH ANDOVER MA 01B45
106,D-0055.0000.0 BERRYSTREET CARDELLO,BRIAN J 576 MAPLE STREET WATERBURY CENTER VT 05766
106.0-0063-=S.M 8 COMPASS POINT ROAD GONZALEZ.MARITZA 8 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-0063.0010.M.10 COMPASS POINT ROAD BRIGHTMAN,CHRISTINA 10 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0012.M 12 COMPASS POINT ROAD JAMES,JEAN-PAUL 12 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0.0063.0014.M 14 COMPASS POINT ROAD SUNKE,PHANI KANTH 14 COMPASS POINT ROAD NORTH ANDOVER MA 01 B45
106.0-0063-0016.N 16 COMPASS POINT ROAD GUPTA,ARUN KUMAR 16 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D•0053-0018.N I COMPASS POINT ROAD DESOUSA,ROBERTO E. 1B COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0.0053.0020.N 20 COMPASS POINT ROAD DIAS,AELSON A. 20 COMPASS POINT ROAD NORTH ANDOVER MA 01645
106.D-0063.0022.N 22 COMPASS POINT ROAD POORNA PAVAN KUMAR MUTNURI 22 COMPASS POINT ROAD NORTH ANDOVER MA 01845
105.04)063.0024.P 24 COMPASS POINT ROAD VENKATRAMAN,VARATHARAJAN 24 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-0063-0026.P 26 COMPASS POINT ROAD CETTIE,JEAN LOUIS 26 COMPASS POINT ROAD NORTH ANDOVER MA 01845
105.D-0063.0028.P 28 COMPASS POINT ROAD MERCURE,DAVID B. 28 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0030.K 30 COMPASS POINT ROAD SAI RAHUL REDDY PULIKUNTA 30 COMPASS POINT ROAD NORTH ANDOVER MA 01845
105.D-0063-0032.K 32 COMPASS POINT ROAD SILA UNSAI 32 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106,0-0063-0034,K 34 COMPASS POINT ROAD GARG,SACHIN 34 COMPASS POINT ROAD NORTH ANDOVER MA 01845
105.D-0063.0036.K 36 COMPASS POINT ROAD CHANDRAN,GOPALAKRISHNAN 36 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0038.J 38 COMPASS POINT ROAD RANGOLI,ANAND 38 COMPASS POINT ROAD NORTH ANDOVER MA 01845*
106.D.005M040.J 40 COMPASS POINT ROAD SAXENA,NITIN 40 COMPASS POINT RD NORTH ANDOVER MA 01845
106.D-0063-0042.J 42 COMPASS POINT ROAD KHAN,KHWAJA M. 42 COMPASS POINT RD NORTH ANDOVER MA. 01045
106,0-0063-0044.J 44 COMPASS POINT ROAD PANCHAPAKESHAN,PAVAN 44 COMPASS POINT RD NORTH ANDOVER MA 01845
1106.D-0063-0045.1 46 COMPASS POINT ROAD ZAMBRANOCEVALLOS,JOSE RICARDO 46 COMPASS POINT ROAD NORTH ANDOVER MA 01845
108.D-0063-0048.1 48 COMPASS POINT ROAD SILVA,JAMES F. 48 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106,D•0063.0050.1-1 50 COMPASS POINT ROAD HOMONNAY,MICHAEL T. 50 COMPASS POINT NORTH ANDOVER MA 01845
105.0-0063.0052.H 52 COMPASS POINT ROAD KANTESARIA,TULAN 52 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-0063.0054,F 54 COMPASS POINT ROAD ALLARD,NICOLE M. 54 COMPASS POINT NORTH ANDOVER MA 01845
106.D-0063-0D56.F 55 COMPASS POINT ROAD VILLEMURE,SCOTT,BRIAN 56 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-W63-0058.F 58 COMPASS POINT ROAD COSTELLO,MELINDA R. 58 COMPASS POINT NORTH ANDOVER MA 01845
106.D-0063.0060.G 60 COMPASS POINT ROAD RICCI,MARK 60 COMPASS POINT NORTH ANDOVER MA 01845
106,D-0063.0062.G 62 COMPASS POINT ROAD SAMTANI,SUNIL 62 COMPASS POINT NORTH ANDOVER MA 01845
106.0-0063.0054.0 64 COMPASS POINT ROAD BRIAN WHIPPLE 2012 FAMILY 45 THISTLE ROAD NORTH ANDOVER MA 01845
106,D-0063.OD66.G 66 COMPASS POINT ROAD VIJAYAKUMAR,SASIKUMAR 66 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0068.D 68 COMPASS POINT ROAD LAKSHMAN,YESWANTH RAO 68 COMPASS POINT NORTH ANDOVER MA 01845
106.D-0053-0070.D 70 COMPASS POINT ROAD JIMENEZ,SHARLINE G. 70 COMPASS POINT NORTH ANDOVER MA 01845
105.D-0D63-0072.1) 72 COMPASS POINT ROAD KHAN,AMJAD 72 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-0063.0074.D 74 COMPASS POINT ROAD VIJAYAN,SWEETHA 74 COMPASS POINT NORTH ANDOVER MA 01845
105.D-0053-0075.0 76 COMPASS POINT ROAD GULLOTTO,DENISE 76 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063.0078.0 78 COMPASS POINT ROAD IMPRESCIA,ANNETTE E. 78 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0053.0080.0 80 COMPASS POINT ROAD ZIMMERMAN,MARK 80 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0082.0 82 COMPASS POINT ROAD MURPHY,BEVERLY A. 82 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-D063-0084.0 84 COMPASS POINT ROAD MOHAMMED NOMAN SIDDIQUI 64 COMPASS POINT RD NORTH ANDOVER MA 01945
106.D-0063.0086.0 86 COMPASS POINT ROAD ADELABU,DETRIS 86 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0053-0088.0 88 COMPASS POINT ROAD MACHADO YOUSSEF,JACQUELINE 88 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063-0090.0 90 COMPASS POINT ROAD CHANG,CHIH-HUI 90 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.0-0063.0092.0 92 COMPASS POINT ROAD GUIDI,MATTHEW 92 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0063.0094.0 94 COMPASS POINT ROAD MISE,KRISTINA 94 COMPASS POINT ROAD NORTH ANDOVER MA 01845
106.D-0053-0096.0 96 COMPASS POINT ROAD QUACH,HAN 95 COMPASS POINT NORTH ANDOVER MA 01845
106.D-0063-0098.0 98 COMPASS POINT ROAD SHABADI,PRASAD 99 COMPASS POINT NORTH ANDOVER MA 01845
106,D-0063.0100.0 100 COMPASS POINT ROAD ERB.SEAN B. 100 COMPASS POINT NORTH ANDOVER MA 01845
108,C-0063-0000.0 303 BERRY STREET 303 BERRT ST NOMINEE TRUST 303 BERRY STREET NORTH ANDOVER MA 01845
108.C-0064-0000.0 325 BERRY STREET DUNN,SEAN,M. 325 BERRY STREET NORTH ANDOVER MA 01845
108.C-006&0000.0 2050 TURNPIKE STREET ZHANG,SHI,YUN 2050 TURNPIKE STREET NORTH ANDOVER MA 01845
108.C-0138-0000.0 7 PALOMINO DRIVE HAMZE,NEVAL• 7 PALOMINO DRIVE NORTH ANDOVER MA 01845
108.C-0140.0000.0 10 PALOMINO DRIVE FOREST VIEW HOMEOWNERS ASSOCIATION 49 GARNET CIRCLE NORTH ANDOVER MA 01045
G
1017/21,12:35 PM Town of North Andover Mail-Application for propane storage 1980 Turnpike st
h
N=ho Patricia Sifferlen < @ mg
Ma 1p ;+�.�'. - ti. psifferien northandoverrna. ov>
Application for propane storage 1900 Turnpike st
Bob Kiicoyne <bkiicoyne@northandoverma.gov> Thu, Oct 7, 2021 at 12:25 PM
To: Patricia. Sifferlen <psifferlen@northandoverma.gov>
Hi Patricia
The Fire Department has no issue with this license application.
Lt. Bob Kilcoyne
North Andover Fire Prevention
[Quoted text hidden]
httos'//mail.aaaale.com/maillu/D7Ik=hl4a447h9Cl&v1Rw=nt&aaarch=nll&nAnnmcaid=man-fa/AA171997AA7r)nRA9R73AR&clmnl=mszri-M.4A 1719A7AA7nn... 1/1
9/27/21,8:37 AM Town of North Andover Mall-Application for propane storage 1980 Tumpike st
QR `�ANQER Patricia Sifferlen < sifferlen northandoverma. ov>
;��' `:I
Application for propane storage 1980 Turnpike st
Paul Hutchins <phutchins@northandoverma.gov> Sat, Sep 25, 2021 at 7:26 AM
To: Patricia Sifferlen <psifferien@northandoverma.g.ov>
The building department has no concerns as long as NAFD guidelines are followed.
On Thu, Sep 23, 2021 at 12:16 PM Patricia Sifferlen <psifferlen@northandoverma.gov>
wrote:
[Quoted text hidden]
httna!//mall.nnnnla.myrJmall/idn9lk=hldndd7hAnP.vlaur-ntRcwwrrh-allAnannmanlri=min.fa/AA1711A77Qnn5.iRR7A7dnRnlmnlzmm-fa,LRA1711Mom,; 1H
9123121,12;55 PM Town of North Andover Mall-Application for propane storage 1980 Turnpike st
.kOMM4 . a .f•
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�Q'°3 RPatriciaS�- Patriciitferlan < si#ferlen� 9 northandovertna, ov> . .
�itassacnu n '` _ P
Appiecation for propane storage 1980 Turnpike st
Jean Enright <jenright@northandoverma.gov> Thu, Sep 23, 2021 at 12:53 PM
To: Patricia Sifferlen <psifferlen@northandoverma.gov>
Planning has no objection to propane storage at this location.
Jean
On Thu, Sep.23, 2021 at 12:16 PM Patricia Sifferlen <psifferien@northandoverma.gov>
wrote!
[Quoted text hidden]
Sincerely,
Jean Enright
Planning Director
Town of North Andover
12,0 Main Street
North Andover, MA 01845
Phone 978.688:953. 3
Fax 978.688.9542
Email: jenright@northandoverma.gov
Web: www.NorthAndoverMA.gov
cid:imageO0l.jpg@OICEOF52.F68A5980
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9/23/21, 12:44 PM _ Town of North Andover Mall-Appllcatlon,for propane storage 1980 Turnpike st
i
OR 'AiQj0qR. ■u: Patricia SifFerlen <psiffe�rlen@northandoverma.gov>
Application for propane storage-1900 Turnpike st
Daniel Lanen <dlanen@napd.us> Thu, Sep 23, 2021 at 12:40 PM
To: Patricia Sifferlen <psifferlen@northandoverma.gov>
The Police Department has no issues with this application.
Lt. Dan
[Quoted,text hidden]
Lt. Daniel R Lanen
North Andover Police Department
Operations Division Commander
E-mail: dlanen@napd•us
Phone: 978-242-1542
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The Commonwealth of Massacltttsetts
Department ofIndustrialAccidents ,
Of floe of Investigations
600 W&htngton Street
Boston;MA 62111
wwrv.mass.gov/dia •
Workers? Com eneati'on Insurance Affidavit: General Businesses
Applicant Ziiformntlon 6 2/�f� Please Print Legibly
Business/Organization
Address: /f ()
City/State/Zip: /� V401/Z Phone#;_ ��� ��J� - �3
Are you an employer?Chet;k the appropriate box., Business Type(required):
I,❑ I am a employer with employees(full and/ 5. ❑Retail
or part time),* 6. ❑RestamantfBar/Eating Establishment
2�rI am a sole proprietor or partnership and have no 7,. E]Office and/or,Sales(inol,real estate,auto,etc,) '
employees working for me in any.capacity,
[No workers'comp,insurtjnc®required]
$, ❑Non-profit
3.❑ We are a corporation and its officers have-exereised 9, 0 Entertainment.
their right of exemption.per%,152,-$](4),and we have 10,[]Manufacturing I
no•employeos,[No workers'comp,insurance required]** 1I.[]Health Care
4; We are a non-profit organization,staffed by volunteers,
with no employees,.[No workers' comp,insurance req.] I 12.[J Other
*Any applicant that chocks box#1 must also rill out the section below showlpg their workers'oompensniion policy Information;
t`if the corporate offioots have exempted themselves,but the corporedon has other employees,a workers'oempenaetlon policy is regvired and such an i
orgaa@a do should cheok-box 11.
tam an employer that is providing worker's'compensation Insurance for my employees, Below is the poi1;Y tit forlrrrrilon,
Insuradoe Company Nione; I
Insurer's A4drelsw.
CitylSt*Zip:
'Polioy#or Self-ins,Lim.,0, Expiration Date'
Attach a copy bf the workers'compensation policy declaration page(showing the policy number and expiration date)..
Failure to secure coverage as required under.Section 25A of MOL a,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 maybe forwarded to the Office of
Investigations oftho DIA for Imuranoe coverage verification.
Idol.,ereby ce grin le_palrts altcl perialtte erfrr .iltat Ure Information provided abo a is true rrel correct
zl
SI atu're! Date:
—33;ro3
I
Official use only. Do not;YrUs In rlsts area,to be eonrpleted.by city or town offlalat
- I
City or Town; Permit/License N.
Issuing Authorlty(circle one):
1.Board of Health 2.Building Department 3.CitylTown Clark. 4,Licensing Board 5,Selectmen's Office
6.Other
Contact Person; Phone#;
wvrw.mess.gvv/dia