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mULOW PIWW APPLICATION POM
psink UK conmal apk 1� POOL
(CUdA wtdOlMrer Apply) fZqPC.ecr OnonAEs
PLEASE PILL OUT UMLY a c=FATELY TO AV=MAY*W pwo0m �
TO THE MPECTOR OF BWWNOB:
It* wWwWgrMd h@MW appYrr for a pWnt b build aoW d M to #* tokw**
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MAIL PEti W T& S KALE % 6paJN A110 .7�'ODt' ,SGPPLf
APPLICATION FOR
PERIRT TO
—I"fLa PQkctics
LOCATION
J?/Z lbfASeN ,/_
PERMIT GPJgffM
v g-�, � z , 2b o� •
APPpOVFD
ze .
OF
CITY OF SALEMO MASSACHUSETTS
a a
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEV J. LISOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form r t
,i
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in: 9EW EM5-4.44D SOI-lb (,)ASTF'
N
A14• (Location of Facility)
Signa re of A
✓f)tiIUATIr l0�s? ��S
Date
Inc(,ammvffwV n '.>Department,of of Indas&W.Accidents
O,d?aa of Inwsdgadons
600 Wasbtngton&Wd
Boston,MA 02111
wwttRmt6sssot✓dGe
Worker'Compensation Insurance AfMavit. BWMera/Contndors/ElecMdansMUmben
ADIDUCS21 Informati Iheam Print Let'U t
Name
Address:
Are youm as emPbycr?er idk appropriate 0 I am a seaaal comae ad I ®New consouctiva
1.® I am a employe with p—• have bired the
cmPloYta(>b11 and/orpart-tie} = 7. jF Remodetma
2.D 1 am a sale proprietor er p� listed m-c amac that
ship sod bm m empkryeea • Theme sub-ccntracl°e have S. ❑ Demoliti�
wonting fo<me is soy capactty wo*W comp.ieanasea 9. D > addition
have es
[No woskaw•comp.inawmw S. ❑ o ar oSltxn e a e exercised ghee ertion and id 10.p Elxaieat tepaQa or additions
of eaemptbn per MGL or additions
3.D II�u s�bomeowuer doing all work t� 11.p Phm:binS repairs
myscW �dim' � J c 1s2,41(4) and we have no 12.p Roof tepees
hwirance regeued.)f empbyces. [No wod:as' 13.0 Ober..
comp.Wm=oe requimd i.
•Anrrov> dochubboxrlU""fmwA*Amcdmbdow&VwbgdW*WdbWaoMPmmftwwd0r
f vks wrumrt W�vb bNowing day m dome dl work ed ors bus oUW&aosbsctas Me wAnit&sew sM&vit�c4; MU
tCmbscom dot cheek nds box met auebad sf adMond des dow'ma ft n w of er mb•aonmidm wd dwk works.•am*PONCr wfor*ri .
I ear a ca'ptayarthebpovldind worAve'cotupcasadm htruranaJer sty emPlAyees J'dow"tk#Puft out Job der
Insmance ComparryName:—
Policy#or Sef--im.Lie,M Expiration Data 4 /j
Joe Sic Adore x d�D city/Stswizip:
Attach a copy of the workers'.eompmudon policy dedwadom pose(ahowb►g the P0119y number Sad esplratloa dale)6
Fatlme to same coverage as required wader Section 25A of MGL c. 152 can lead bo the imposition of ahnind penalties of a
Sae up to$1,500.00 aadtor one-yea:kwdso=mcK as wen as&A pmsities in the form of a STOP WORK ORDER and a Sue
of up to$250.00 a dry asaimt the violoor. Be advised that a copy of this satement may be forwarded 10 dw OSIce of
lavestissdom of the DIA br int w=ce coverase veriScalim•
I do Awmy tem*under AePOW and0ndrla oJPNJW that the hs wwddfox PVW&d a sm b true and ewre"
QmW
6A d
ojkld use W* Do no*Tft In A&aret,to be ewaviaudy cavort"O,O OimE
Cky er Towm Pes m Celffi a b
Issaing Autborby(dreg one):
1.Board of Heakh 2.Building Depart at I Ckyfrown Clerk d.Elubical Inspector S.Plumbing Inapeetor
6.Other
Conrad Perseus Phones:
Massachusetts Gemini Laws chapter 152 requires all employe»to provide workers' Compensation for their employees. .
Pursuant to this statute. an employer is dcfined n"...everyperson in the serviceofaiiother u any contract ofhang
express or implied.Oral or writtei' "
An eavploye►is defined as"an in&"partaas*associate ompmtioa or other W entity,or any two or more
of the foregoing engaged in ajoint cowriss,and idxhding tits h sl representatives of a deceased employs,or ft
raeiva or.trnatee of sa iodiyidual.partnership,association or otter legal entity.employing employees. However the
owner of a dwelling house having not mom than three gwbncM and who reside thaei4 or the ocapmt of the .
dwelling house of moths who employs persons in do mamtemmom Construction or repair wort on such dwelling borne
s on the grou&or building appmunaes&crew shall>ot because of sack employment be deemed to be m employs.'
MGL chapter 15Z 12SC(6)also states that"every state or local licensing ageaq shad withhold the Issuance or
renewal of a tleense or psmk to operde a bestow or to con trod buddlap In the eom®onnakh for W
appoint who hat ant produced acceptable aldea a of eomptl m with the.wouraaessowage required."
AdditiooaDy.MCd.cbaP>h 352.42sC(1)stko"Neither the commica seahh ow ny of its postisl mbdivisiom sban
eoW into say contract fin the perfinumoc ofpublie wait until acceptable evidence of oompfisnee with the insurance
nquircmns s of ft diapter have bees presented to the contracting authority"
APP��
please fill oui the wwkeas'Compe andon atBdavit completely,by chal®g the boxes that apply to your situation and,if
nay,supply sub-oo (s)nameft address(es)and phone moaba(s)along widl their cati8cate(s)of
kwa neL Limited Liability Companies(LLC)or I hdmd Liability Pumashipt(i.LP)with no employes other thus dse
members or parmdif, are not m*ed to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised shut d tb affidavit may be submitted to the Department of brdastrial
Accidents for confirmation of ioswance coverage. Ain be sure to sip sad date the afildsvIL The affidavit sboald
be returned to due city or town that the application ter the permit or srxme is being requested,ant the Departmeut of
Industrial Accidents.. Should you bave any questions regarding the law a re ifyou a required to obtsia a workers'
compensation poky,plea call>be Depatrnrs at the samba listed below Self-insured Compares should eats the
self-iasduamx license mmba oa the lies
Clty or Town Otlsdsbi
Please be sure toot the affidayh is complete and printed legibly. The Department bas.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 appHcaot
Please be we to fill in the permiftense m,mI which w,71 be used as a refam a number. In addition,an appHcaes
that most submit multiple pe mit/sceose applications m any gives year,need only submit one affidavit indicating current
policy mSmmanon(if necessary)and undo"Job Site Address"the applies,,*should write"all locations in (city or
town}"A copy ofthe affidavit did has boa officially stamped or,mwW by the city of towel may be provided to the
applicant as proefdot a valid affidavit is on file for 14tnre permits or liccnwL A new affidavit most be filled out each
yew where a bome owner or citia m is obtaining'a license or permit not related In any business at commercial venture
(ie.a dog soma or parrot to burn leays sae.)said person is NOT required so complete tuft affidavit
The Offim of Imvesagations would blre to thank you in advance for your cooperation and should you have any questions,
picnic do not bedM b`give its 2 CIL
The Department's addrw,tehpbow and ft:nombw.
The Cotmaonwe'atth of Massachusetts
Department of Industrial Accident..
Otfitx ttf Invt'rt�atltim
600 Washington Sftd
Boston,MA 02111
TeL #617-7274900 ext 406 or 1477-MASSAFE
Fax#617-727-7749
Revised 5-26-O5 wwwmass.gov/dia
OneBeacon_
I N f U F A N C e WORKERS COMPENSATION
" AND
EMPLOYERS LIABILITY POLICY
" TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S24UB-8o4X767-A-05)
RENEWAL OF (6S24UB-804X767-A-04)
INSURER: ONE BEACON INSURANCE COMPANY
NCCI CO CODE: 80233
1.
INSURED: PRODUCER:
CROWN AUTO BODY SUPPLY LLC GERALD T MCCARTHY INS
45 MASON STREET 92 NORTH STREET
SALEM MA 01970 SALEM MA 01970
Insured is A LIMITED LIABILITY COMPANY
Otherwork places and identification numbers are shown in the schedule(s) attached.
2. The policy period Is from 10-25-05 to 10-25-06 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
o�
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
ftem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
I
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
a- Plans. Ali required Information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 09-14-05 CM ST ASSIGN: MA
OFFICE: ONEBEACON INS 820
PRODUCER: GERALD T MCCARTHY INS \ 73MBB
003750
i�
I " S U R A N C E WORKERS COMPENSA
AND 2"- 5
EMPLOYERS LIABILITY POLI ( 1k
;P
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS24UB-804X767-A-05)
CLASSIFICATION SCHEDULE:
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S)
SIC-CODE: 5531 MA BUREAU FILE NO:
------------------------------------------------------------------------------------
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 6098
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 284
TERRORISM RISK INS ACT 2002 122
TOTAL ESTIMATED PREMIUM 6504
TAXES AND SURCHARGES 268
DEPOSIT AMOUNT DUE 6772
A/R (WCIP) #
Minimum Premium: $ 248
ST ASSIGN: MA
DATE OF ISSUE: 09-14-05 CM
OFFICE: ONEBEACON INS 820
PRODUCER: GERALD T MCCARTHY INS \73MB6
One Beacon.
J N s u a n N c N WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A)
POLICY NUMBER: (GS24UB-804X767-A-05)
INSURER : ONE BEACON INSURANCE COMPANY
INSURED'S NAME : CROWN AUTO BODY SUPPLY LLC 80233-MA
RATE BUREAU ID: 000179570
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
CLASSIFICATION TOTAL ANNUAL PER $100 OF ANNUAL
CODE REMUNERATION REMUNERATION PREMIUM
LOCATION 001 01
FEIN 043545365 ENTITY CD 001
CROWN AUTO BODY SUPPLY LLC
45 MASON STREET
SALEM, MA 01970
AUTOMOBILE ACCESSORY STORE-
RETAIL-NOC & DRIVERS 8046 232499 2.45
5696
SALESPERSONS, COLLECTORS OR
MESSENGERS-OUTSIDE 8742 98278 29
288
CLERICAL OFFICE EMPLOYEES NOC 8810 �, 76133 15
114
C jl
ZZ
MA MANUAL PREMIUM $ 0
---------------------------------------------------------------------
1 .000 MERIT RATING MODIFICATION NONE
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 6098
284
0.0300 TERRORISM RISK INSP ACT E2002S(9740)900) 122
4.40% MA WC SPECIAL FUND AND TRUST FUND 268
TOTAL ESTIMATED PREMIUM 6772 772
DEPOSIT AMOUNT DUE 6772
3757 DATE OF ISSUE: 09-14-05 CM ST ASSIGN:\A SCHEDULE NO: 1 OF LAST