HomeMy WebLinkAboutComplete Variance Application - Application - 4/25/2025 TOWN OFNORTH ANDOVER
ZONING BOARD OF' APPEAL,S
i
°1 own. ptct t����r�� rau��p
.,Justin Parker of Classic Signs
ADDRESS OF APPEAL." 350WinthropAve, North Andover, ass e s s, 01,8145
Procedure & Requirements
for an Application far aVarlmnce
"I"welve 1 copies of tile ll in in formati r 111.rl t The Office of Zonitlg Board of Aplaeals schedulesail applicant
stibillitted thirty days prior rw to,the first public l r-in . for a hearing date and,prepares p ar till legal notice f r mailing t
Failure to submit the required irrforma tion within the nl'ne the at-tl in int ire (abutter and for publication in,the
periods prescribed niay result in a dismissal by the Zoning newspaper. Tile petitioner is notified that the legal notice lra
Board d 1 ail application as incotripliete. been prepared rred and the cost of the Flarty in Interest fee.
''lire inforniation herein is ail abstract of niore specific
r cpuircine its listed in the Zoning Board Rules and SITPI : DELI V RV OF LEG I,NOTICE TO
Regulatiotilsand,is not niewit to sUplersedeth rll. The NE SP EI .
titi n r will corer Late items,that are underlined. The p enti rr r picks s r.rp tile peal notice ftoni the Office ofth
Zoning Board of APpeals and delivers tli legal notice to the
STET' 1. ADMINISTRAT"OR PET. IrT DENIAL:IAA: local flew p l p r f6'r p rrbli ati n.
'rile p titi n r applies for aMlildtllg P rniit and receivesa,
Zoning Bylaw Denial t rrl conipleted by the Lrrl 'in STEP 1 PUBLIC HEARING BEFORE THE ZONING
Tile petitioner hOUI.l appear ar rl his/her behalf, r be
STEIN : VARIANCE APPLICATION F I I-6 represented ail agent or attiorney. In the n fai
Petitioner + m pl t art application p li ation form to,petition the Board appearance With0lit(lr,re Genres on lr if o the petition,the
µ *, c. i . . a µ M � Board hall decide 1 r�r the im tt r using tileinf rtn tr r it has
�l�Appeals,lr Variance. ill rrrr r��r�rtrr� l��rll r��pl�t��l� �
X
received to date.
STEP 3: PLAN PI.EPAR 'TI uN
Petitioner subillits all of the required ed plan information as cited STEP DECISION:
N
in page 2,section, f this f rni. A ftei.(Ile Ilearin anddecision, copy of theBoard' le i i r1
will � filled, in,t�he Office f tile Town Clerk arid sent,to the
STEP : OBTAIN MST OF PAR`I`T IN"It"IIIES T. petitioner n all Parties in, Interest,Aiiy appeal of the I rrr 1
"I'll I'l tition r requests the Assessor's Officeto compiledecision nmy be made p rrrstiant to Massachtisetts,Genelal Law
certified list r T" r•ti in Interest l rrtt r� h. �� , . ",,within t ent la after the decision i 1 ,
with the Town Clerk.
STEP 5: SUR ITT APPLICATION:
Petitioner grit_ one p ri ina] and eleven(11),copiesof all STEP I � RECORDING,THE ECI I N' N "I"I.
required h6ormation to the'rown Clerk's Office to be certified PLANS.
by the down Clerk vitl the time and (late of filing.. The The petitioner is responsible foi-recording,certification f til
% Office, �l r r li, nd n�� om earl in.� �lan art th F' unt ,
r.�r��r �rr� l 1���11 p ��r1.r��rttr taw t1 �" M��w�r� � r ��r��l t1� l �.
11 copies, i11submitted t tile Zoning Board 1 p p rrrl North Registryf e(k- rli n Street, Lawrence CIA I
secretary. and shall complete the f Recording forill and
forward it to,the Zoning Board orAppeals and to the rril.ding
STEP 6: SCHEDULING OIL HEARING AND Departnient.
PREPARATION OIL LE AL NOTICE,'*
UMPOICIAN't"PHONE NUMBERS:
978-688-9533 Officeof Community Dev. &Servi 78-688-9501. Town Clerk's f ce
North ndovei-Town Hall 9 8- - s r�s Office
I 'Ma i tl,Street,
North Andover,MA 0 1845
978-688-9542 Fax ffir Community Development offices
978-6889545 Building Department
° - -9 1, Zoiling'Board of App t's, . f1
NORTH ANDOVER ZONING G BOARD OF APPEALS petition for a VARIANCE
IN1P0 R 1.A N`I`, A PI"LICA NT N1 .".S r ("0 114 YJ1, ,r 1, AL,1, Yrf.",AM S 0 N THI S 110R N1
PETITIONER INFORMATION
NAME: Justin Parker of Classic Signs Inc. L C
ADDRESS: 13 Columbia Drive,Amherst NH, 03031
PHONE: 8-51 - 008 MAID: justin@classicsignsnh.com
if th,#p etition ei-an(1 orp#-opegv 01 I'll eo-is a coutpm 1, coIpo ratio 11 or other etiti(ly,a list of tyre nrrmes and a f1dres es of fli e
SUBJECT PROPERTY INFORMATION
LOCATION 0 F 1)ROPERT : 3 50 Wi nth r Ave, North Andover, MA, 0 184 5
ZONING DISTRICT; B3 ASSESSORS PROPERTY MAP NO.:027
LOT NO.
..... . ..............
OWNER 01' RECORD: Delta MB LL.0 C e eulas Super Markets,ets, IN
DEED RECORDED Al" ESSEX NORTH REGISTRY OF DEEDS AT:
BOOK: 1 088 PAGE 0027 OR CER'I1PICATE NO.:
RELATIONSHIP TO SUBJECT PROPERTY(i.e. owtier, abutter, etc.):
Authorized Agent
CURRENT USE: Grocery Store
PROPOSED USE: Grocery Store
PREVIOUS VARIANCE GRANTED-D- YES NO x DECISION NOJDA'm
OTHER. REGULATORY REVIEW: YES NO x IF YES, DESCRIBE STATUS:
EXISTING CONDITIONS DESCRIPTION:
here, is curre fly anAnterna mated set of cbannd letteLsAinstalled.onto the facade of the building.
Page 2 of
1
NORTH ANDOVER ZONING BOARD of APPEALS petition for a VARIANCE
PROPOSAL DESCRIPTION
1. BrIefly describe all proposed changes to the tract re ' and/or use ;
..Te....b. 11dig.i ..undergoing..r. . cvtic ,.. d... .. . w.. i gn.. i11...b. .Jnstll .d..ire...t ... . ... . r1... r . ,...in..th ... . m ...style,...and...................
generally the same size of what is existing. This new sign will be internally illuminated,ted, which is also the case for the
eiting-sign.-In conversations- rith building commissioner-Paul-Hutchins...tr was--n o--priou s-- rriane-for-the...existing
.........
sign.
......................... ... ...............................................................................................................................................................................................................................................................................................................................................................................................................
.. ... .......... .......... .... ................................................................. ..............................................................................................................................................................._
........ .. ...... ...... ... ................................................................................ .....................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. State all sections of the Noi-th Andover Zoning Bylaw it p lira e l in this variance petition:
.We...are.. .e.eki.ng.r .lie.f..fro ...c Ater....1. . ... rtiei.e..... . .. ..'Fl o.... ig ....shall...b.e...lighted,.... . c.ep.t...b.y.... teady,... .t. ti.o . r ....11 .s.... iel . .............
and directed solely at the sign. Internally fit signs are not allowed."
. State the specific relief being sought fi-orn the North Andover Zoning Bylaw, including all ordinance
e
dimensional requirenients and proposed c irne sio al conditions:
s:
:.The...specific...relief we...are... .e.el ing..i ...to...allnw.an..internally,illuminated... et...of..chann el..letter ....to-be...installed-onto....th ....f a de.............
of the building
.
........................................................... .... . ............................ ....... ... ..... .
. Identify and describe all plans and supporting .hoc nient being s binitt rl with this vartance Petition:
T. .ere...i .... ...propo ed...dra i g..I l d. ..wit .Ahi ...application.....]t...i dl tes-th t-the.... .igrr-will...l.e-in .tall.e ....o. to....t ....I. c ..... .f...:.t ..........
building after renovations, The sign will be installed in the same general area as the existing sign. There is a picture
Page 3 of
NORTH ANDOVER ZONING BOARD OF APPEALS petition for a VARIANCE
.showing..t .e.eistig. oditions.. .f.the.site,.. ..w.ell.. ... .. .pie.. .. .erhd...view... f..the..site..Tleer. ..is.. ls.o...an.o.wner.'s.........
authorization fora, workers comp affidavit, and a certificate of liability insurance included in this application as well.
............................................................................ ..........................................................................................................................................
................................................................................................................................................................................................................................................................................................
.. ......................................................................................................................................................................................
SUPPORTING STATEMENT
��#,��.'#�� ��,FOL l...%. 1VI '( l 1_-_01�r��\1r:�1EN L I•S. R,A 1-`.A h�i��. Ih II."JIt.:ST 11/-1-I' F.I 111L/S1 i�'��.��.A'R)St,
THEFORTH�'t�/ *R. T�I��i�v��T�i � i...i�i�i� !-f�F
7'HE f.1PPL 1 C.I_.-V1'[V;.IC ' 1? --I:VC" IiII'll G.L. C. 40,1,§1(1.
. Describe a the special ciremiistaiiees related to soil eorrditioris, the slrai a or the topography of the lard or
ti•rieture that are rirYi ue to the par-eel:
The.. re.vio u sly..e isting.sign.h as.intern al.illumination..T e..gr nti n g-of-th is...variance...will.a 11ow.a.. onti nu ation..of--th e...cu rrent..........,
conditions of the site.
........................................................................................... .. ............................................................................................................................................................................................................................ ... ...
.........................................................................................................................................................................................................................
. ............. ..
. Specify how the circunistances do not generally affect ther- properties hi the zolthig district:
.The..previously.existing. i AsJ t r.n ll ..illuminated,.. ...th r ... rill..n t.b. ... .drastic.. ...tr m r i . ly-exi ti .....................................
conditions.
... .... .. .. ... ..... ........ .. ,
. Explaiii how the liter-al enforcement of the North th ndoveri Zoning Bylaw will result in a stibstaiitial
liai-dship to theowner:
. ...disallowing...internal..illu ination...of.A e...sign,..t is...Mar e.t.. as et..will...have...severely...deereased..a vertisernent., ring-night.....
time hours, which could result in a decrease in sales.
...................................................................................................................... . ..... . ... ..... ...... .......................................................................................................................... .......................................................................................................................
. Explain how the proposed variance is the miiiinitrrri elmige that is necessary to allow the reasonable 11se
of'the land orstructure:
r I
ant'ng..the...proposed.-variance...wi .a ow...the..in er.n ..i flu mination..o....t.e...sign....... .e...pre.vio. s y...e is.ting.sign..has-internal............................
Illumination, but no variance was tiled for that specific sign.
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................
. Explain why graifflng the pi-opo ed variance will be hi i arrrioiq with the prrrpose aird hitent of the
Nox•th Andover Zoning Bylaw:
Page 4 of
w
NORTH ANDOVER ZONING BOARD OF APPEALS petition for a VARIANCE
.Granting.th e.. ropo d variance WII all o t..thl s b usiness...t e. a lr rn-arno.un ..of..advertisement-to-the.most a ou�t.of......................
people possible, especially during night time business lours.
... . .... ... . . .........................................................................................................................................................................
. Describe the impact on the neighborhood and how it will not be (t triniental to the neighborhood or the
public welfare.
Tine..pr viou sly-existing-- Ign..cu rr ntly...lna .and..ha ..had internal illu r xoatlo ..al ready....T ...alto. an e-of.this.-vari a n ..would...........
have less of a change to the existing conditions of the site. The proposed sign will also be of a very similar style and size
....................................................................................................................................................................................................................................
f the existing sign.
........................ . ..............................
7 . Difference froin Zoning Bylaw requirements: Indicate the dimension(s) that will not ineet etirrent
Zoning Bylaw Regtflrenien s. Lines A and B in ease of a lotsplit)
Lot Area Sq. Ft. Open Space Percentage Lot Frontage Parking
Sc. Ft Cov rage Feet Spaces Front Side A Side B Rear
A. %
B.
7 . Existing Lot:
iinimum Lot Setback
Lot Area Sq. Ft, Open Space Percentage Lot Frontage Parkiltg
.Ft. Coverage__ Feet Spaces From Side A Side B bear
7C. Proposed Lot:
N ini:t uni Lot Setback
Lot Area Sq. Ft. Open Space Perc entagc Lot Frontage Parking
Sq.Ft. Coverage Feet spaces Front Side A Side B Rear
°o
ONO
D. Regtflred Lot: (As required by Zoning Bylaw&Tani 2
Nf ininitim Lot Setback
Lot Area Sq.Ft. Open Space Percentage Lot Frontagjo Parking
Sq.Ft. Coverage Feet Spaces Fron( Site A Side B Rear
r
Page 5 of
F
NORTH ANDOVER ZONING BOARD OF APPEALS petition for a VARIANCE
A. Existing tflidi s :
round Floor Sq. Number of Total Sq. Number
Ft. Floors Height Ft. U of Building* of Units*
* erere€Ices Uses from(fie Aming Bykaw&Table 1.
State number r 1 units in building(s).
8B. Proposed Buildl"119(s):
r tincl Floor Sq. NUmber of Total Sq. Number
Ft. Floors Height Ft. Use off' ui1cling* ofUnits*
*References Uses fi'0€11 01C 011irh,Bylaw Tabl
e 1.
State,number ofunits in buiIdincy(s).
PROPERTYOWNER CONSENT, CERTIFICATION & SIGNATURE
I air(we are the owners of the property subject to this variance petition and I we consent and certify as
follows:
I. f we grant permission for officials and employees of the Town of North Andover to access my property
for the purposes of this petition;
2. l N e certify that we have reach the Board's Rules and Procedures before submittal to ensure the
ompleteness of ri-iy(our) petition;
. f we certify that all the staten-leots Nvithin this application and attachments are tide and accurate to the
pest of my (our) knowledge and belied'.
X 41 120 5
Petitioner ignatu (Date)
X See Attached 4/16/2025
(Petitioner Signature) (Date)
y lica le
Name of Attorney/Agent for Applicant:Justin Parker of Classic Signs Inc. LLC
Mdre s s o r Attorney/A ent:
Phone Number of Attorney A ent
Email Address of Attorney A.genl:
Page 6 of
Y
NORTH AV ER ZONING BOARD OF APPEALS petition for a VARIANCE
9, PLAN OF LAND 6. Dames addresses and phone
Each application to the Zoning board of Appeals shall IlUmbers of the applicant,owner or
be accompanied by the following described plan. record,and land surveyor.
Plans must be submitted with this application to the 7. Locus
Town ClerkI s 0 ftic:e and the Z B A secretary at [east
thirty days prior to the public heariag before the 9. D. Minor Projeet
Zoning Board of Appeals. Minor projects,such as(leers,sheds,and
gat-ages,shall require only the plan information
A set cif building elegy{atloii plans by a Registered as indicated with an asterisk * . In some eases
Arelixtect iiia.. be r uit-e(l Mien the application further inforination lnay be required.
hivolves iiew coji trtictioiticoiiNFet'siotilaii(l oi' a
proposed change iii use. 10. APPLICATION FILING PEES
10.A. Notification fees: Applicant shall provide
. A. Major Projects a check or money order to:'"'Town of Noilli
T hor projects are those,which involve one of the Andover"for the cost of first class,certified,
following whether existing or proposed: return receipt x##of all parties in inter•em
1). Five 5 or more parking spaces, [de tit ilied in M.G.L ch.40A§l I on abutter's list
11). Three 3 or more dwelling units, for the legal notice check. Also,the applicant
111 .2,00o square feet o f bu i I d i ng area. shall supply first class postage stamps for each
Major Projects shall require,that in addition to the 9B address listed on the abutter's list, plus are
'9C feature, that the plans s liow detailed utilities, additional two 2 for the decision nnailing.
soils,and to ogr-aphic information. 10.1 . Mailing labels: Applicant shall provide
*9. B. Plan Specifications: four 9 sets of inaiIing labels no I(arger than
I). Size of plan: 'Ten 10 paper copies of l'4 2- /1" Three )copies for the Leal,and
plan not to exceed I I"x 1 ", one 1 copy for the Decision mailing).
Preferred kale of 1" 40'
11). Plan shall be prepared, stamped and 10. C. Applicant shall provide a cheek or
certified by a 1 e i terecl Profes ioual money order to:"Town of North Andover"per
awl Surveyor. Please note that platys the 2005 seised Fee Schedule.
by a registered Professional Engineer.
Registered d Architect,and/or a A Variance mice lei mated b F the A will
Registered Landscape Architect inay lapse iii oiie 1 year if not a ei-cised mid a new
be required for k ajor Projects, petltimi must be submitted
. C * ec uirecl Features On Plan.
1). Site Orientation shall include:
I Noilh point
Zoning district
3, farms oftr•eets
4. We(I and s i f applicable)
5. Abutters of property,within 3 '
radius
. Locations of buildings on adjacent
properties within 5 ' from
applicants proposed structure
. deed restrictions,easements.
11). Leg ncl & Gi-aphic Aids shall
iliclude:
l. Proposed features in solid limes
outlined in red
. Existing features to be removed in
dashed lines
3. Graphic scales
4. Date of Plan
. Title of Plan
Page 7 of
Zoning Bylaw Denial Form =
t2o Dill SUM
North nd vei�,Mai, 01845
Photi -688- Fax 3- - 2
Strut: 350 WInthrop Avenue
a (Lot:
027,E-07
Apploant; Justin Parker s
k
f
Request,. Vadanc
Eal ; 4117/2025
l
Plea so ba advised that after review of your Appl Ica Ilon and Plans that your Application Is 0ENI E D for the fol lowltig ZmAng
Bylaw reasons:
zonilig
Item Notes Item Notes
A F o 1Lot Area Frontage -
1
1 Lot area Insufficient Frontage Insufficient -
Let Area Preexisling 2 Frontage ComplIes
Lot Aroa Cv i lies 3 Preexisting frontage
4 Insufficient Information 4 Insufficient Information
Use 6 No access over Fronle e
1 Allowed G ContI uous Building Area
2 Not his fft lont Aron
Use Pr exisfig 2 Complies t
5 dal Permit Ike eired 3 PfOOXIS(Ing,C13A
Insufflcient Informa#ion 4 In uffl eni Information
Setback H -BuIldhig HekAhl
r
I All setbacks comply 1 Ike hl Exceeds Maximum
2 Front Insufficient 2 Complies
Left Side Insufficient 3 Preexisting_Hal( a
Right Side InsAdent 4 In ufficfent Information {
Rear In uffident I BuildIng Coverage
Pfeexisling so(b ecis Govern a exceeds maximum �
7 Insuf dent I f rmallon 2 Coverage Complies f
Watershed Govern a Preexlslin
i
4 Not In Watershed 4 i'os ffi llent Information
2 In Watershed i Sian
Lot pr!or to 10/2 1 4 1 Siannot allowed x
4 Zone to be Det rmhed 2l a r iie
Insuffl ent Information 3 Insufficient Information
Historic District K Parkh
1 In District review requIred 1 More PatkhiQ Required
2 Not In distf 2 Parking Coy lies
lnsuffi lent Inf natfon 3 In uffiolent Information
f're-existingPaiking
Remedy for tho ala vo Is checked below.
Itom# Speclal l ermIta Naming Board Item 9 Variance
SIte Plan ReviewS e i l Porn! Setback
Access Other(Ilan Fronte L e al Pern�lt parkin
IR onla a E o lion Lot Special Permit Lot Area
Common Ddvekya S aclal Pa mill Height
Con re t ush c al Permit
3 Sign
e
f '
Continuing Care Rellreme t Special Pemilt Contiguous Buildhig Area
lade gndant Elde rly H p usin q. S000t i Pe mil I Special Permits Zonffig Board
Laroe Estate Condo Spa dal Permit So eolaI Permit No n-Con formlp7 g Use Z8A
Planned Development District Special Permil Earth Removal Spa 'al Permit ZBA
Planned Residential e lal Permit a fiat Permit U not Listed but Similar
R-6 DonsiN Spedal Permit pedal permit for Sign,
Watershed pedal Permit a laf permit for proaxisfing nonconforming
Front -
Plan Review narrative
The following narrative Is provided to fudher explain the reasons for DENIAL for the APPLIGAT(ON for the propetty Indleated on the reverse side:
7 1
95,.6 5. Prohibitions*
[Amended 5-14-2019 ATM by Art. 30; 6-17-2021 ATM by Art, 311
A.
No sign shall be lighted, except by steady, stationmy light, shielded and directed solely at
the sign. Internally fit signs are not allowed. Applicant is requesting an Internally lighted
sign in the Business 3 Zoning District,
The above review and attached explanation otsuch Is based on tho plans and Information submitted. No definifivo review and or advice shall be based on
verbal explanat1w ns by the applicant nor shall such verbal explanations by ilia applicant sure to provide definl tive answers(o the abovo reasons for Any
Inaccuracles,misleading Information,or other subsequent chatigas to the Information submi(ted by Ilia applicant shall be grounds for Oils revlew to be
voided at the discretion of the Building Depadment.The attached document titled"Dian Review Narrative'shall be attached horeto and Incorporated
herein by reference. The building depMment will retain all plans aad documentaUon for the above file.You must file a new pe[n)it applic all oll form and
begin the parniftfing process.
__Mzarch 19 2025 4117/202.5
}/�B411dlnrg�Ue MmZ'e�nl Official Signature Applicatlon Received Application Denled
Den la 1Sent:. 4 11 71202k It Foxed Phone NumberfDato:
Roforred To:
Fire X Health
Police X ZonIng Board
X Conservation Dopadmant of Public Works
X Planning Historical Gommlss�on
REVISION. / /22
7
OrN
111111111011
Item A) Manufacture one niii set of LED channel letters forth new facade_
4'-11 1
9 - _ 3 -510
meivaur"lin"u,on timm wnwic.ir"Ou-mg may vary 001ij from trw_—kOuot-AS BU ItT upon li Ongln"i P L
Color-and r rut orn im;Ywrla arc,mir rtpr-_U4*ft t!vv of lineal r j-i duo 10 it'd waWa!Mai tbnQ!_�:
U L L Icensed Man ufacturor
Th.s dravAngprotected by U.S.copyright Iii Any use{reproduction,copying or exhibiting this dravving without the express written consent of Classic Signs iis lillegal,
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350 Winthrop
Ave, Andover, MA -
Google Map--�--:; Zoning District: B3
Map#. 027 Lot#: 0027
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Imagery @2025 Airbus,Maxar Technologies,Map data&)2025 1
Abutter to Abutter BuIldin 1)ej)1. ( ) Cons er a(ion Zonin
OWN OF NORTH N R
ABUTTER LIST
REQUIREMENT: I CL 40A,Section 11 states in part"Patties in interest as used 1n(his chapter shall mean(he petitioner,
abettors,owners of land directly opposite on any public or private way,and abutters to abutters within
thfee hundred 600)feet of the properly line of the pallitio er as they appear on the most recent applicable
tax list,not withstanding that the land of any such owner is located in another city or town,111e planning
board of the city or town,and the planning board of every abutting city or town."
SUBJECT LOCATION OWNER ADDRESS CITY STArE ZIP
02 7.0-00 7-0000.0 3 5 D WINTHROP A VENU DELTA MB LLC 875EASTSTREET TEINI(SOURY 4AA 01876
PARCEL ID LOCATION OWNER ADDRESS CITY STATE ZIP
02 .0-0007-OD00,6 10 W OD#IDGE DRIVE WOOD RIDGE HOMES LLC 10 WO DRIDGE DRIVE NORTH A D VER MA 01845
026.0-0006-0000.0 WINTHROP OP AVENUE DELTA MB LLC 875 EAST STREET TEWKS 3 RY CIA 01876
026.0.0008-0000.0 WINTHROP AVENUE DELTA CAB LLC 875 EAST STREET TEW SB RY MA 01876
026.0-GO09-0000.0 WAVERLY ROAD DELTA SIB LLG 875 EAST STREET T WI SB RY 11A 01876
6 7.0-D006-0000.0 691 WAVERLY ROAD CORRELLE 2015 REVOCABLE TRL)s,r 691 WAVERLY ROAD NORTH ANDOVER IA 01845
627.0-0007.0669.0 669 WAVERLY ROAD BROD RICt,SUZETTE,O. 669 WAVERLY ROAD NORTH ANDOVER MA 01849
0 7.0-0007.0 71.0 671 WAVERLY LY ROAD NIZAMOV,ARTEMIY 671 WAVERLY ROAD NORTH ANDOVER MA 0184
627.0-0008-0000.0 667 WAVERLY LY ROAD ADLEY,THOMAS F. 667 WAVERLY ROAD NORTH AND OVER MA 0184
027.0-0003-0000.0 659 WAVERLY ROAD C NNALLY,JILLIAN 659 WAVERLY ROAD NORTH ANDOVER AAA 0184
0 7.0-0010-0000.0 665 WAVERLY ROAD RIVERA,LAWRENCE 655 WAVERLYROAD NORTH ANDOVER IA 01045
027.E-001 1-0000.0 647 WAVERLY ROAD A AR ,WILLIAM 647 WAVERLY ROAD NORTH AND OVER iA 01845
027.0.0012-0000.0 639 WAVERLY LY ROAD DESOUSA,SUSAN B 639 WAVERLY ROAD NORTH AND ER CIA 01845
627,0-0013-0000.0 633 WAVERLY ROAD PARR,WON 633 WAVERLY ROAD NORTH A ID VER fV1A 01845
27.0-0014-0000,0 629 WAVERLY ROAD ETCHI ,GENNADlY 629 WAVERLY ROAD NORTH ANDOVER MA 61845
027.0-00 0-0000.0 WAVERLY ROAD DELTA MB LLC 876 EAST STREET TEWKSBURY MA 0187
027.0-0031-0000.0 WINTHROP IP VENUE DELTA MB LLC 875 EAST STREET TEWKSBURY MA 01876
that the nvm&P OU4
records Of 918 AIM
b :
Ater recording turn to:
S adden,Arp ,Slate,Meagher&Flom LLP
Four Times quare
New Yor New York 10036
1 ttenti Vered Rabia
QUITCLAIMDEED
:.
0
Delta&Delta Realty,, a Massachusetts partnership, (the"Grantor")with an address of c/o
Demoulas Super Markets, Inc.,875 East Street,Tewksbury, Middlesex C lwy,Massachusetts
08176,for consideration of one dollar $1. , grants to Delta MB LL ,a Delaware lin ted
-44
liability company,with an address of c/o Demoulas Super Markets,Inc., 875 East Street,
Tewksbury,Middlesex Counter,Massachusetts,08176,
with quitclaim covenants
kn
en
the lard as more particularly described on.Exhibit A attached hereto,
45
subject to taxes and assessments not yet due and parable, any existing easements,rights of way
and other encumbrances and restrictions of record to the extent in force and applicable.
For reference to Grantor's title see deed recorded herewith,For title of A.T.Demoulas, as
Trustee of Delta&Delta Realtor`gust,see Quitclaim Deed recorded in the Essex North Registry
of Deeds in Book- 1278,Page 1 ; Quitclaim Deed recorded ire the Essex North Registry o
Deeds in Book.1278, Page 13;Quitclaim Deed recorded in the Essex North Registry of Deeds
in Book 1299,Page 379, as confirmed by Deed recorded with said Deeds,Bo6k 1301,Page 7 8;
Quitclaim feed recorded in the Essex North Registry of Deeds in Book 1648, Page 267.
The consi&ration for this conveyance is less than$100.00 and,the deed is being 91V en between
related entities as part of a corporate or parent entity rest oturin ;therefore,the State Excise
Stamp Tax is not applicable.
Grantor is not classified as a corporation for federal income tax purposes.
I ArKAWWWNRains and enalties of perjury, that:
LAWYE R S TITLF/00 M MO?JWEA1-I H 4411AN D WTLE
COMMERCIAL SERVICES 07F r-
266 F T E ET, Ff I-Lo o p
ATTN'. FILE N .
The undersigned is a member and the Managing Pminer of Delta&Doha.Realty—A
Partnership(the T a ersbip" pursuant to section 1 c of the Confirmatory Partnership
Agreement dated February 2 , 1984,as amended on March 5,2002(the"Agreemenf
which is in full force and effect;T.A.Demoulas,the original Managing Partner,having
died on May 24,2003,
2. The above conveyance is in the usual course of the Partnership's business;
. The conveyance does not involve anything which may not be done by less than all of the
partners as set forth in M.G.L.c,, 108A, §9.
[Reinainder of.gage Intentionally ,�Blank]
Z. .0
AD-;.ZX' C as a sealed instrument as of the date first above written.
GRANTOR:
DELTA&DELTA REALTY
Massachusetts general paitnership
dame: Arthur T. Demoul s
Title: Managing Partner
[Signature page to Deed#2—Store #12)
COMMONWEALTH OF MASSACHUSETTS
COUNTY OF SUFFOLK, ss.
On this `day of December,2014, before me,ttie undersigned notary public, r onall
appeared Arthur T.Demoulas,prowd to me through satisfactory identification,which was
valid � of or [based on the undersigned's personal knowledge of the identity of the
principal],to be the person whosename is signed on tie preceding or attached document, and
acknowledged o me that he signed it voluntarily for its stated purpose as Managing Partner o
Delta&Delta Realtor.
(Official Signature and f eat of Notary)
Printed Name: -ems moo'..OkL
My Commission Expires: Oq 11(3 aa
'M
ANDREW T MAUDE
t Naryfic
flip GGMMOnweafth Of Maftxhoft
v wv w vwvw'rwwvwvwwvv]
[Signature page to Deed 42—Store#1 2
AFFIDAVIT OF GRANTEE,
The grantee,Delta MB LLB, hereby affirins that it has no ktiowledge of any lack of
authority on the part of Arthur T. Demoulas,Managing Paitner of Delta&beita Realty,the
person executing oxeouting this instrument um of conveyance.
Executed under the penalties of perjurythis � day of December,2014.
DELTAMB LLC, a Delaware limited liability
company
DELTA&DELTAS REALTY, a
Massachusetts general partnership, its sole
member
y
Name. Arthur T. emoulas
Title: Managing Part er
[Signature page to Deed#2—Store 12]
COMMONWEALTH of MASSACHUSETTS
COUNTY OF SULK, ss.
Can this day ofDecember, 2014, before me,the undersigned notary public,personally
appcare,d Arthur T.Dernoulas,proved to me through satisfactory identification, which was a
valid(kiver's ficense, to be the person whose name is signed on the preceding or attached
document, , and who swore or affirmed to me that the contents of the document are truthful and
accurate to the best of his knowledge and belief.
(dffici"al Signature and Sea'rof Notary
My Commission.Expires*
} NDREW
Notary ,tbli
Commonwealth of
Maswkisft
F r� iion expires sapter i0
,�
[Signature page to Deed #2—Store 12]
XIBI
Store #12
360 Winthrop Ave North Andover MA
EXHIBIT "Alp
The following parcels of land located in North Andover, Essex county, Massachusetts:
Parcel.,,
The land on the easterly side of Winthrop Avenue and Waverly Road in North Andover, Essex County,
being shown as Lots C and D and a parcel marked ed"John P. &Kastant J. Shay"on a Plan entitled, `Plan
of Land in No. Andover, Mass,", dated Jan. 12, 1966, by Dana F. Perkins&Sons Inc.,civil Engineers
Surveyors, recorded with said Deeds as Plan No, 6764. The parcel marked ed`{John P,. & Kastant J. Shay"
as shown on said Plan is on the westerly side of Waverly Road and abuts Lot D to the west; and
acM 2w
The land on the northeasterly side of Winthrop Avenue, North Andover, Essex County, being shown as
Lot A on a Plan entitled,"Plan of Lard in North Andover, Mass., surveyed for Demoulas Realty Trust
dated Dec, 31, 1965, by Dana F. Perkins&Sons Inc., Civil Engineers&Surveyors, recorded with said
Deeds as Plan No. ; and
.Parcel
The land on the northeasterly side of Winthrop Avenue,, North Andover, Essex County, being shown as
Lot B on a Plan entitled, "Plan of Land in North Andover, Mass,, Surveyed for Demoulas realty Trust!
dated Dec. 31, 1966, by Dana F. Perkins&Sons Inc., Civil Engineers&Surveyors, recorded with said
Deeds as Plan No. and
Parcel :.
The land on the northeasterly side of Winthrop Avenue, North Andover, Essex County described a
follows:
The land in North Andover, Essex County, Massachusetts,,containing 5.94 acres, more or less, and being
shown on a plan of land entitled, "Plan of Land Located in No. Andover, Mass., owned by: John P. and
Kastant J. Shay, shoving Proposed Rezoning", dated Nov. 1964, Charles E. Cyr, Civil Engineer,
Lawrence, Mass., which plan is recorded with said Deeds as Plan No. 534Z. The rand is more accurately
bounded and described as follows: +
Beginning at a point at the N 0 RTHWESTE RLY most corner of the premises, said point being the
SOUTHWESTERLY most corner of the premises now or formerly of Den Rock Drive-in Theatre, Inc.; and
thence turning and running In a
N 0 RTH EASTERLY direction by said Den Rock D rived n Theatre, Ino. land fora distance of 674,59 feet,
more or less,to a point; and thence turning and running in
NORTHERLY direction for a distance of 130 feet, more or less, again by said Den rock Drive-In Theatre,
Inc. land; and thence turning and running In an
EASTERLY L direction for a distance of 100 feet, more or less, through land formerly of John P. and
Kastant J. Shay, to a point being the NORTHWESTERLY corner of land now or formerly of Baird; and
thence turning and running in a
4 18- 4 4=7 1 .1
4
Store#12 (continued)
350 Winthrop Ave North Andover MA
8OUTHERLY direcflon, on a curved course., for a distance of 6 4.44 feet, more or less, by lard now or
formerly of said Laird, Beattie, Camparone, Hoar, Correlle, l e vh r t and Bingham, to a point being the
SOUTHWESTERLY corner of land now orformerly Buchanan; and thence turning and running in
WESTERLY direction for a distance of 100,06 feet, more or less, through land formerly of said John P.
and Kastant J, Shay- and thence turning and running In i
SOUTHWESTERLY direction fbr a distance of 263.55 feet, more or less, again through lance formerly of
said John P.and l astant J. Shay to a point at Winthrop Avenue; (for an additional reference depicting the
last two courses, see plan of land entitled, "Plan of Land Owned by Myrtle Shay located in North Andover,
Mass.", dated August, 1976, Charles E, Cyr, Civil Engineer, Lawrence,.Mass., which plan is recorded with,
said Deeds as Elan No. ; and thence turning and running In
NORTHWESTERLY direction by said WinthropAvenue for a distance of +feet, more or less, to the
point of beginning; and
Parcel i
The laird on the northeasterly side of Winthrop Avenue, North Andover, Essex County being shown a
Lot 1 on a Plan entitled, "Plan ofLand Located in forth Andover, MA, Pre pared for Township Realty
Trust dated .wire 24, 1980, by Frank C. Gelinas &Associates, 5rigineers Architect, recorded With said
Creeds as Flan No,
TOGETHER WITH an Easement for water pipes as set forth in a grant to Telemachus A. Q e o [as and
George A. Dernou as, Trustees of De mo ulas Realty Trust,dated Ja nuary 3_ 1966, r car ed with said
Deeds, Book 1051. Pao L684 `
t
I Normand Martin of Delta MB f-AX
(Properly ownel's name.) (busilless name,when (applicable)
located at 8756) Street rFewksbL11-Y, MA 0 1876
mv 11 e l' S m a i l M LY a d d I'e 4 s ,..f..,..w,W...»,......�,��
} hereby aUt orize Classic Sips Inc. ofAmher t Now Hampshire
t
to
act as agent for the 11' OSe Of PUISUilIg required sign permits Or
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aria lot, �r o be � �pleted
7
s
54
f
Market Basket 350 Winthrop Ave, 'N Andover
9
sign location street address)
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Appi-*oved bY.- 'ale �e'
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s i a n atu re cif`prope ty mmer 1%�Ik Ai (phone number
ge *Clci-y �*c S gns:
.y
Date: �3
� ��
� CERTIFICATE LIABILITYINSURANCE DATE(IMroo1YYYY)
0/041 0 4
THIS CERTIFICATE IS ISSUED AS A FATTER OF I N FORM TI N ONLY AND CON F ERS NO R IG HTS U PON THE C EF TIEI CATE HOLDEN.THIS
DEf TIFI CATE DOES NOT AFFIF MATIVE LY 0 R NE ATIVELY AMEN D,EXTEND 0 R ALTER THE COVERA E AF FO I DED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN U EI { },AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAILED,subject to the terins and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endola semelnt(s).
PRODUCER CONTACT Stacie L Vallee
NAME:
HPM Insurance pka The Holt Agency PHONE7 -1 01 FAX
{ � � (60 )673-4825
AID NG.Ext.
101 Pon mah Road,Suite-t E-MAILStacie c ipmin urance.com
AD DRESS:
INSURER( )AFFORDING OVERAGE NAIO�#
Amherst NH 0031 INSURER A: Aoaldia Insurance Company 31325
INSURED INSURER B
CLASSIC SIGNS INCINSURER
13 COLUMBIA DRIVE INSURER D
BAY 016 INSURER
AMHER T NH 03031 INSURER I~
COVERAGES CERTIFICATE NUMBER: CL2410440773 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM R CONDITION OF ANY CONTRACT OR THER DOCUMENT ENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I# R POLIO'EFF POLICY E P
LTR TYPE OF INSURANCE I SD WVQ POLICY NUMBER f1✓~,'U�3DlY1� �' I'�1�'i�iaDlYYYY LIMITS
COMMERCIAL GENERAL LIA131LITY
EACH OCCURRENCE
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES Ea ec ufrence
ME EX (Ally one pe{son)
PERSONAL&ADV INJURY
EN'LAG REO TE LEMITAPPLIES PER: GENERAL AGGREGATE
POLi �PR -JEOT F LOG PRODUCTS-CO KIP/0P AOG
OTHER,
AUTOMOBILE LIABILITY COMBINED:3 SINGLE LIMIT
Fa accident
NYAUTO BODILY INJURY(Per person)
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Par accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS SS LIAR CLAIMS-MADE AGGREGATE
€}E D RETENTION
WORKERS OoMPENSATICIkN X STATUTE R T
AND EMPLOYERS'LIABILITY Y 1 N
A ANY PROPRIETOMPARTNER/E ECUTIVE N NIA 1� �1 1� -1 1f}11�11 I� 'I�11�1f 0 ,� 1,000,000
(3I�iFIOitRlikrE=t� l=t E( Ll.1C} i1 ❑ - E_L.EACH ACCIDENT
(Mandatary Its NCI) E.L.DISEASE-EA EMPLOYEE 1,000,000
If Yes.d sc4ba under 1 000 O0
DESCRIPTION OF OPERATION belo:v E.L.DISEASE-POLICY LIMIT '
DESC RIPTION of OPERATIONS}LOCATIONS 1 VEHICLES (AGORD 101,Addilronal Remarks Schedule,may be attached if more space is required)
Paul Tripp is an inducted officer for WC benefits.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION }ATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
120 Maim Street
AUTHORIZED REPRESENTATIVE
North Andover, MA 0 1845
1988-2015 ACORD CORPORATION. All frights resented.
ACORD 25( 016/ 3) The AD RD name and logo are registered ni rks of AC I D
ADDITIONAL COVERAGES
Ref# Description Coverage Code Form No. Edition Date
VAC&Employer's liability WC EL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
$15,760.00
Ref# Description Coverage Code Form No. Edition Date
Adjst.to reconcile-e p reed.premium AREM
Limit it I Limit 2 Limit 3 Deductible Amount Deductible Type Premium
-$1, 'I .00
Ref Description Coverage Code Form No, Edition Date
Domestic Terrorism, Earthquake&Catastrophe DTEC
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
$-10,00
Ref# Description Coverage Code Form No. Edition Date
Premium discount P J
Limit'I Urnit 2 Limit 3 Deductible Amount Deductible Type Premium
-$ 0 . 0
Ref## Description Coverage Code Form No. Edition Date
Increased employer's liability INEL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
$1 7 .00
Ref Description Coverage Code Form No. Edition Gate
Expense constant EXC T
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
1 0.0
Ref# Description Overage Code Form No. Edition Date
Limit I Limit 2 Limit 3 Deductible Amount Deductible Type PremILI M
Fief# De criptlori Coverage Code Fora No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref## Description Coverage Dole Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref# Description Coverage Cade Form No. Edition Date
Limit I Limit 2 Limit 3 Deductible Aniount Deductible Type Premium
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
FADTLCV Copyright 2001,AIMS Services,Inc.
x
J
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
C 00 03 13 04 84
WAIVER OF OUR
ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
Any Person or organization for Whom You are Performing Operations
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below vwr is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement ent Effective Policy No. Endorsement No.
10 01/2024 W A 5320149 1
Insured Premium
Classic Signs Inc
Insurance Company: Countersigned by
Acadia Insurance Company
WC 00 0313 04 84 @ 1983 National Council on Compensation Insurance Page 1 of I :.
The Commonwealth of Hassachitsetts
DepartineW ofln(lustrialAccideiits
� = Office f hive gations
Lafayette ' vii ter
2 Avenue de La0yette, Bostoti, MA 02111-1750
7
wwwitiass.govIdia
Workers' Compensation In tirance Affidavit: ii*l ei#s Coiit ctors Electr ci s Plum Applicant hiforin tioii Please Print Le � l
Name Btislji s/ t-g liization/lildi idtial : Classic Signs Inc. LLC
Address: 13 Columbia Drive
City/State/Zip:Amherst, NH, 03031 Phone g: 03-8 3- 3 4
Are you an employer? Check the appropriate box: Typeproject r�'e t i• �i� red ;
1•1 I i amployt•with �
• I am a general contractor and I
employees full and/or pa
��t�tiiiie .�` have hired the sit -eot�tracto��s
. E] New construction
1
. I a soleproprietor o�• t•tt et;- listed on the attached sleet. � . 0 r e� odeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity, employees and have workers 9. Building addition
[No workers' comp. insurance comp. insurance.+
required . F1 We are a corporation and its 10. Electrical repairsor additions
.�
311 I am a homeowner doing all work officers have exercised their 1 l. Plumbing repairs or addition
myself. No workers" comp. right o exemption per MGM 12.0 Roof repairs
insurance ce required.] '� c. 152, §1(4),and we have too
employees. No workers' 1Other
comp. insurance required.]
Any applicant teat dieeks box#1 mu st also fill out the section be low showing th it worker's'com1)ensation policy information
f Hoineowners who sub init this affidavit iadieating they are doing all wo rk and then hire outside con(ract rs must submit a new a Midavit indi cating such.
-�Contra tors that elieck this box must attached an additional sheet showing the name of(lie sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp,policy Number.
unt(tit einplojper tacit is pro i din workers'coinpe rsation insrcr•ance for my entplojwes. elt)) is the oll*cgyp iitdjob.vitcA
Insurance Company Naille: HPM Insurance
Policy##or Self ins. Lie. M WCA5320149-17 Expiration Date: 10/0 1 2025
Job Site Address: 350 Winthrop Ave, North Andover, MA o 1845 City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (late).
Failure to secure coverage as required under Section 2 A of MGL,e. 152 can lead to the imposition of criminal penalties of
fine up to $1,500.00 and/or one-gear imprisonment, as N ell as civil penalties in the fora-i 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 foti arded to the Office of
Investigations of the DIA for insurance coverage verification.
do hei-eby certify and r the pains and pen allies of pe1.7Ur P t eat the information prorpr'ded aboi#e is true an d correct.
. 411 f� 2 2
Si t��r e. ]ate.�
Phone 978-514-4668
Of
.ficial use only. Igo not write in this(trea, to be complested k17 c.io) or town o ciaL
City or Town: .......,.,.....__ Permit License
Issuing Authority(check one):
1❑Board of Health 20 Building Department 30Cit r `own Clerk Electrical Ins)eetor 50VItinibing
Inspector 6.MOtlier
Contact Person: Phone#:
4Informati'on. and Instruc
Massachusetts General Lays chapter 152 requires all employers to provide workers" compensation for their employees.
Pursuant to this statute, an einlVr,I ee is defined as "...every person in the set-vice of another under any contract of lire,
express or implied, oral or�,Nr#itten."
An einph 17er is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling louse laving not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair-work on such dwelling 110LIse
or on (lie grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."'
I L chapter 152, § 5C 6 also states that "every state or local licensing agency shall withhold the issuance or•
renewal of a license or perm t to operate a business or to construct buildings in the eoninionwealth for any
applicant who has not produced acceptable evidence ofcompliance with the insurance coverage required."
Additionally, MGL chapter 152, 25C states "Neither the commonwealth nor any of its political subdivisions Shall
enter-into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers" compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) n me s , address es and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees others than the
members or partners, are not required to carry workers" compensation insurance. If an LLC or L.LP does have
employees, a policy is required, Be advised that this affidavit may be submitted to the I epartnnent of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and (late the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain workers
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number can the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicam
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information if*necessary and under",lob Site Address" the applicant should write `all locations M _ (city 01.
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
ppli ant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
i.e. a clog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you M advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02 1- 7,50
Tel. 727- 900 or 1-877-MASSA E
Fax 617 727-77 9
Devised 7- 01
ww.iliass.gov dia