HomeMy WebLinkAboutUntitled Department of Fire Services
ba" Office of the State Fire Marshal
P.O. Box 1025, State Road, Stow, MA 01775
CERTIFICATE OF REGISTRATION
North Andover April 30, 2024
(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): Greater Lawrence Sanitary District
(ADDRESS): 240 Charles Street
is the holder of the license granted (Date): 6/21/1976 for the lawful use of the building(s) or other
structure(s) situated or to be situated at (ADDRESS): 240 Charles Street
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.
Received .... ........... ..2024......... .. .....�....... .......:...........................
(Sign
By ... (,�.................. ature�.....................
(0fficia it ) (Clerk) (State whether owner,occupant or holder)
(Address)
Department of Fire Services
it '�' Office of the State Fire Marshall
a'
bys r P.O. Box 1025, State Road,Stow, MA 01775
REGISTRATION
North Andover, April 30, 2024
(City or Town) (Date)
This is to certify that Greater Lawrence Sanitary District
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: Greater Lawrence Sanitary District
is the holder of the license granted(Date)6/21/1976
for the lawful use of the building(s)or other structure(s)situated or to be situated at: 240 Charles St
as related to the KEEPING, STORAGE, MANUFACTURE OR SALE OF FLAMMABLES OR EXPLOSIVES.
¢'..........
(Signature and Official Title) Cleric
Note:A certificate of registration must be filed on or before April 30`1 ofeach year.
(THIS REGISTRATION MUST BE CONSPICUOUSLY POSTED ON THE PREMISES.)
EXPIRES APRIL 30,2025
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Lelribl y
Business/Organization Name; Greater L awrPn�P yaw District
Address: 240 Charles Street
City/State/Zip: North Andover MA 01845 Phone#: 978-685-1612
Are yot!an employer?Check the appropriate box! Business Type(required):
14 I am a employer with employees(full and/ S. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2,❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales(inc1,real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑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,❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp, insurance req,] 12 Other,Municipal Wastewater Plant
*Any applicant that checks box 41 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 on
organization should check box N1,
I am an employer that is providing workers'compensailon insurance for my employees, Belory is Me policy Information.
Insurance Company Name: MEGA
Insurer's Address: 55 Walker Brook Dr. , Suite 402
Citylstate/zip: Reading, MA 01867
Policy#or Self-ins,Lic;# X34069 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 andior 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
Investi ations of the DIA for insurance coverage verification.
I do hereby certtf un r its attd penaltl of perjury that the information provided above is true and correct.
Sig_riature: Date:
Phone#: 7
Official use only. Do nor sprite to this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I•Board of Health 2.Building Department 3.City/Town Cleric 4, Licensing Board 5,Selectmen's Office
6.Other
Contact Person: Phone#t
www.mass.gov/dia