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HomeMy WebLinkAboutUntitled v; 1, �'�bss garb 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): AIMCO/TTA MS 235 (ADDRESS): 3 Galleria Tower 13155 Noel Rd Ste 100 LB 235 Dallas TX 75240 is the holder of the license granted (Date): 04/26/2023 for the lawful use of the building(s) or other structure(s) situated or to be situated at (ADDRESS): 28 Royal Crest Drive 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 holder of the license if said license was granted prior to July 1,1936, Otherwise by the owner or occupant of the land licensed. 11,000 gals pr ane Received ...........................2023......... ByV. �f� S� L^ (Signature) + .. (Official Title) (Clerk) (State whether owner,occupant or holder) -- II (Address) 1 The Commonwealth of Massachusetts } Department of Industrial Accidents ;­47 Office of Investigations -�. ........ Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www mass-gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant-In formation Please Print Legibly Business/Organization Name: II. A 1 `� �OY� AYIdJVcr Address: _c Ropa� rf"5'l' r" City/State/Zip:_ &2,��, AnAwef i MA a 1845 Phone #: 97,— 3 yG — Iq 35 Are you an employer? Check the appropriate box: Business Type (required): 111 I am a employer with -7 employees (full and/ 5. ❑ Retail or part-time, * y b• ❑ \l JtCallrailtiLal/EQttns Establ-'shmerit 2.❑ [ am a sole proprietor or partnership and have no 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 no employees. 10.❑ Manufacturing [No workers' comp, insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 1 1•❑ Health Care with no employees. [No workers' comp, insurance req.] 12.© Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. , **lf the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation poliev is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: " E 1135,�Qrwk Insurer's Address: y3 6 Uzi r\\,� 4 City/State/Zip:_ PLUAOP��w) -FR 1q(o1- Policy # or Self-ins. Lic. # 'WL ( 5 07 3h'q 1 A Expiration Date: ,a l i � 1013 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 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 a penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: 713 — kop 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): LOBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.OOther Contact Person: Phone#: www.niass.gov/dia