___________FAX: __________________ E-Mail_____________________________ Dates of Auction: _____________________________________________________________________________ Hours of Operation: ___________________________________________________________________________ State License Number: __________________________________Expiration Date: ______________________ (Attach copy of current State License) Complete and return the enclosed Affidavit from the Department
Workers Compensation Affidavit - Complete the enclosed Affidavit from the Department ofIndustrialAccidents in reference to MGL 152 chapter 152, section 25 Workers Compensation Insurance. Proof of Workers Compensation Insurance - Certificate of Insurance or Information Page from Workers Compensation Insurance Policy. Certificate must name Licensing Coordinator as Certificate Holder at address below.
Workers Compensation Affidavit - Complete the enclosed Affidavit from the Department ofIndustrialAccidents in reference to MGL 152 chapter 152, section 25 Workers Compensation Insurance. Proof of Workers Compensation Insurance - Proof of Workers Compensation Insurance Certificate of Insurance naming Licensing Coordinator as Certificate Holder at address below or Information Page from Workers Compensation Insurance Policy.
Signature of Applicant: __________________________________________________ For City Use Only: Police Treasurer Building Fire Comments: __________________________________________________________________ W/C Affidavit W/C Proof By-law Article V Health & Safety, Section 7 LIC210063 The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation
Yes No Signature of Applicant __________________________________________ City use only: Building Treasurer Police Fire Comments: ________________________________________________________________ __________________________________________________________________________ Proof of Workers Compensation Insurance Workers Compensation Insurance Affidavit The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston
Workers Compensation Insurance Affidavit Proof of $25,000 Bond The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia \ a e) > 0) ER il 1H ( LOT a bie In il II ! EN Workers Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY.
Page 2 The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_________________________________________ __________ Address:__________________________________________________________________________ City/State/Zip:
Be advised that this affidavit may be submitted to the Department ofIndustrialAccidents for confirmation of insurance coverage. Also be sure to sign and date 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 ofIndustrial Accidents.
Workers Compensation Affidavit - Complete the enclosed Affidavit from the Department ofIndustrialAccidents in reference to MGL 152 chapter 152, section 25 Workers Compensation Insurance. Proof of Workers Compensation Insurance - Certificate of Insurance or Information Page from Workers Compensation Insurance Policy. Certificate must name Licensing Coordinator as Certificate Holder at address below.
The debris will be disposed of in: 19 Nak Way Location of Facility | We CMe Signature of Applicant te/iy/ er Date ' Dedicated to excellence in public service ae The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.
Status Delinquent for: Unpaid Past Due Real Estate X x Personal Property X xX Utility Billing tan x Owner HAS THIS BUSINESS BEEN ISSUED PERSONAL PROPERTY BILLS: YES NO Approved Carolyn Lyons Treasurer/Collector Date Received: Date Completed: Applicant The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors
DEPARTMENT OFINDUSTRIALACCIDENTS, Respondent Appearance for Appellant: Pro Se Marie McBride Appearance for Respondent: Suzanne Quersher, Esq. Director of Labor Relations EOLWD 19 Staniford Street: 5th Floor Boston, MA 02114 Commissioner: Christopher C. Bowman ORDER OF DISMISSAL On January 20, 2015, the Appellant, Marie McBride (Ms.
The debris will be disposed of in: Tose aie rill _\)t\ \\wste Locatjon of Facility Signature Dancers of Applicant lb[20/ 202% Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.
The debris will be disposed of in: Twos Pe ml _\i, Location \Wwste hee of Facility Signature of Applicant Ib[zo}202% Date Dedicated to excellence in public service eae The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.
Status Delinquent for: Unpaid Past Due Real Estate X x Personal Property X xX Utility Billing tan x Owner HAS THIS BUSINESS BEEN ISSUED PERSONAL PROPERTY BILLS: YES NO Approved Carolyn Lyons Treasurer/Collector Date Received: Date Completed: Applicant The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors
Food Employees for Establishments Serving the General Population: https://www.mass.gov/files/documents/2016/07/te/guideline-food-general.paf Guide for Industry: Excluding and Restricting Food Employees for Establishments that Serve a Highly Susceptible Population: https:/Awww.mass.gov/files/documents/2016/07/pz/quideline-food-susceptible. pat S: Environmental Health / Forms & PDF's Updated 10/3/2018 Page 3 of 7 The Commonwealth of Massachusetts Department
Be advised that this affidavit may be submitted to the Department ofIndustrialAccidents for confirmation of insurance coverage. Also be sure to sign and date 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 ofIndustrial Accidents.
Friday office hours are reduced to 8:30 a.m. to 2:00 p.m, Forqueso, please call the Framingham Public Health Department at 508-532-5470 S:/ Environmental Health / Food Related / Applications & Forms Updated 10/7/21 Page 5 of 10 ill I Congress Street, Suite i Boston, MA 02114-2017 a = Ld moe The Commonwealth of Massachusetts Department ofIndustrialAccidents 100 www.mass.gov/dia Workers Compensation Insurance Affidavit: General Businesses.
Page 3 of 6 The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass. gov/dia Workers Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY.
Food Employees for Establishments Serving the General Population: https://www.mass.gov/files/documents/2016/07/te/guideline-food-general.paf Guide for Industry: Excluding and Restricting Food Employees for Establishments that Serve a Highly Susceptible Population: https:/Awww.mass.gov/files/documents/2016/07/pz/quideline-food-susceptible. pat S: Environmental Health / Forms & PDF's Updated 10/3/2018 Page 3 of 7 The Commonwealth of Massachusetts Department
Be advised that this affidavit may be submitted to the Department ofIndustrialAccidents for confirmation of insurance coverage. Also be sure to sign and date 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 ofIndustrial Accidents.
Friday office hours are reduced to 8:30 a.m. to 2:00 p.m, Forqueso, please call the Framingham Public Health Department at 508-532-5470 S:/ Environmental Health / Food Related / Applications & Forms Updated 10/7/21 Page 5 of 10 ill I Congress Street, Suite i Boston, MA 02114-2017 a = Ld moe The Commonwealth of Massachusetts Department ofIndustrialAccidents 100 www.mass.gov/dia Workers Compensation Insurance Affidavit: General Businesses.
Page 3 of 6 The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass. gov/dia Workers Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY.
The debris will be disposed of in: City uty Location of Fdcility Sfirrature of Applicant 7 (23 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.
The debris will be disposed of in: CA, Aru bi ' Location of Facility Q 2 ~Sgnature of Applicant I silos Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia umbers. Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pl TO BE FILED WITH THE PERMITTING AUTHORITY.