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Department of fire Services
Office of the State Fire Marshal
P.O.Box 1025,State Road,Stow,MA 01775
CERTIFICATE OF REGISTRATION
Nortli Andover April 30, 2023
(City or Town) (Datc)
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 Or FIRE SERVICES.
In accordance with the provisions of Chapter 148, Section 13,of the General Laws,the undersigned hereby certifies that:
(TITLE HOLDER 1503 Osgood St LLC
1503 Osgood St
is the holder of the license granted (Date):_October 24,2006 for the lawful use of the building(s)or other
structure(s)situated or to be situated at (ADDRESS): 1503 Osgood Street NORTH ANDOVER, MA 01845
(City orTown)as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
NOTE: This certificate of registration must be signed by the Bolder of the license if said license was granted prior to July 1,1936,
Otherwise by the owner or occupant of the land licensed. 22,500 gals gasoline —7,500 Gals Diesel
Receiv .... V."�. .
J ..................
(Signature)
By . ...........y ..., Authorized. . .Rep. fo..r Owner.................
(Ottici i ) (Clerk-) .. ... ... ... ... ......
(State whether owner,occupant or holder)
685 Grandview Ave. Columbus, OH 43215
................................ .....................
(Address)
(yl } Department of Tire Services
�ob� Ga Office of the State Fite Marshall
sSNKo,�°' P.O.Box 1025,State Road,Stow,MA 01775
REGISTRATION
North Andover, April 30,2023
This is to certify that 1503 Osgood St LLC. (City or Town) (Date)
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: 1503 Osgood Street LLC
is the holder of the license granted (Date) 10/24/2006
for the lawful use of the building(s)or other structure(s)situated or to be situated a1503 Osgood ST
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
22,500 gals gasoline
7,500 Gals Diesel
l
Note:A certificate of registration must be filed on or before April 30'"of each year. (Signature and Official Title) Clerk
(THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.)
EXPIRES APRIL 30,2024
The Common ivealth of Massachusetts
Department of bidustHal nil ccidents
z Office of Investigations
' Lafayette Cily Center
2Avenue(le Lafayette, Boston, MA 02111-1750
" t ►vmv.inass,goj,/dia
Workers' Compensation Insin-ance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 786 Shell, Inc.
Address: 1503 Osgood Street
City/State/Zip: North Andover, MA 01845 phone#: (508) 366-1529
Are you an employer? Check the appropriate box: Business Type(required):
1,® I am a employer with 6 employees (full and/ 5• a Retail
or part-time),* 6. ❑Restaura it/Bar/Eating Establishment
2,❑ I am a sole proprietor or partnership and have no (� Office and/or Sales{itncL real estate, auto,etc,}
employees working for me in any capacity, 7.
[No workers' comp, insurance required] 8, ❑Non-profit
3,(] We are a cozporation and its officers have exercised 9. ❑Entertainment
their right of exemption per e. 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,❑Health Care
with no employees. [No workers' comp. insurance req] 12,[l Other
*Any applicant that checks box it l must also till out Uie section below showing their workers'cornpensalion policy infornmtion,
**If the corporate officers have exempted themselves,but tho.corporation has other employees,a workers'compensation policy is required and such an
organization should check box#T,
lam an employer thatlsproWhig workers'compensadotn lnsitratncefor my employees. Below is the policy lirfarinatiorl.
Insurance Company Nalne: Travelers Insurance
Insurer's Address: One Tower Square
City/State/zip: Hartford CT 06183
Policy#or Self-ins, Lic, It U13-2T189913-23-42-G Expiration]Date: 02/18/2024
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,
X do Hereby certify,ttrtder ilie pales-artd peitalties.ofperfttry that the hiformation provided above is true and eorrect,
Signature: r —
Date: 04/19/2023
Phone#: 888-519-5023,
Offielal ase only, Do not write In this area,to be completed by city or town offlelat.
City or Town: Pertnit/License #
Issuing Authority(cheep;one):
IE]Board of Health 2.❑Building Department 3.[]City/Town Cleric 4.❑Licensing Board
508clectmen's Office 6,nOther
Contact Person: Phone H.
mvw,mass.gov/dia