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135 LAFAYETTE STREET - SIGN PERMIT - DAILY TABLECity of Salem Sign Permit Application Worksheet Zoning (res/non-res)R3 residential Entrance Corridor (Y/N)Y Lot frontage 275 feet Building or tenant frontage 100 feet # of businesses on site 1 Bldng dist from street center <100 feet Multiplier 1 Building and Blade Signs maximum area permitted 100.00 sq ft total proposed sign area 83.90 sq ft Sign 1 (wall sign)31.51 sq ft width 275.00 inches height 16.50 inches Sign 2 (awning)26.19 sq ft width 82.00 inches height 46.00 inches Sign 3 26.19 sq ft width 82.00 inches height 46.00 inches Freestanding Signs NONE maximum area permitted 32.50 sq ft (per side) maximum # of signs permitted 1 signs maximum height permitted 12.50 ft tall Sign 1 (parking) proposed sign area 13.00 sq ft length 52.00 inches height 36.00 inches Application meets guidelines set forth in the Salem Sign Ordinance Yes Recommend approval Yes 13-Jul-23 Daily Table 135 Lafayette Street Notes: Sign meets dimensional requirements for the ordinance. This sign review worksheet is associated with E-23-504 for sign illlumination. SP-23-40 & SP-23-41 City of Salem Sign Permit Application Worksheet Zoning (res/non-res)R3 residential Entrance Corridor (Y/N)Y Lot frontage 275 feet Building or tenant frontage 100 feet # of businesses on site 1 Bldng dist from street center <100 feet Multiplier 1 Building and Blade Signs maximum area permitted 100.00 sq ft total proposed sign area 83.90 sq ft Sign 1 (wall sign)31.51 sq ft width 275.00 inches height 16.50 inches Sign 2 (awning)26.19 sq ft width 82.00 inches height 46.00 inches Sign 3 26.19 sq ft width 82.00 inches height 46.00 inches Freestanding Signs NONE maximum area permitted 32.50 sq ft (per side) maximum # of signs permitted 1 signs maximum height permitted 12.50 ft tall Sign 1 (parking) proposed sign area 13.00 sq ft length 52.00 inches height 36.00 inches Application meets guidelines set forth in the Salem Sign Ordinance Yes Recommend approval Yes 13-Jul-23 Daily Table 135 Lafayette Street Notes: Sign meets dimensional requirements for the ordinance. This sign review worksheet is associated with E-23-504 for sign illlumination. SP-23-40 & SP-23-41 existing elevation qly-1 set U.L. listed LED internally illuminated channel letters mounted to raceway/s -color to match brick white acrylic faces w/brilliant green translucent vinyl applied (similar to PMS 375C) black trimcap and returns digitally printed translucent vinyl logo by SAR (green to match brilliant green) ......... 41 ... .. ..._,,,__, POST GRAVEL CONCRETE BACKFILL __ 36" __ ___ 6'' City of Salem Sign Permit Application Worksheet Zoning (res/non-res)R3 residential Entrance Corridor (Y/N)Y Lot frontage 275 feet Building or tenant frontage 100 feet # of businesses on site 1 Bldng dist from street center <100 feet Multiplier 1 Building and Blade Signs maximum area permitted 100.00 sq ft total proposed sign area 83.90 sq ft Sign 1 (wall sign)31.51 sq ft width 275.00 inches height 16.50 inches Sign 2 (awning)26.19 sq ft width 82.00 inches height 46.00 inches Sign 3 26.19 sq ft width 82.00 inches height 46.00 inches Freestanding Signs NONE maximum area permitted 32.50 sq ft (per side) maximum # of signs permitted 1 signs maximum height permitted 12.50 ft tall Sign 1 (parking) proposed sign area 13.00 sq ft length 52.00 inches height 36.00 inches Application meets guidelines set forth in the Salem Sign Ordinance Yes Recommend approval Yes 13-Jul-23 Daily Table 135 Lafayette Street Notes: Sign meets dimensional requirements for the ordinance. This sign review worksheet is associated with E-23-504 for sign illlumination. SP-23-40 & SP-23-41 City of Salem Sign Permit Application Worksheet Zoning (res/non-res)R3 residential Entrance Corridor (Y/N)Y Lot frontage 275 feet Building or tenant frontage 100 feet # of businesses on site 1 Bldng dist from street center <100 feet Multiplier 1 Building and Blade Signs maximum area permitted 100.00 sq ft total proposed sign area 83.90 sq ft Sign 1 (wall sign)31.51 sq ft width 275.00 inches height 16.50 inches Sign 2 (awning)26.19 sq ft width 82.00 inches height 46.00 inches Sign 3 26.19 sq ft width 82.00 inches height 46.00 inches Freestanding Signs NONE maximum area permitted 32.50 sq ft (per side) maximum # of signs permitted 1 signs maximum height permitted 12.50 ft tall Sign 1 (parking) proposed sign area 13.00 sq ft length 52.00 inches height 36.00 inches Application meets guidelines set forth in the Salem Sign Ordinance Yes Recommend approval Yes 13-Jul-23 Daily Table 135 Lafayette Street Notes: Sign meets dimensional requirements for the ordinance. This sign review worksheet is associated with E-23-504 for sign illlumination. SP-23-40 & SP-23-41 07/10/2023 Morse Insurance Agency, Inc. 285 Washington Street North Easton MA 02356 N. Del Sole (508) 238-0056 (508) 230-8367 chuckdelsole@morseins.com SIGNS BY J, INC. 100 TENEAN ST BOSTON MA 02122-3620 Union Insurance Company 25844 Acadia Insurance Company 31325 Selective Insurance Company of the Southeast 39926 22-23 A CPA5021320-21 12/18/2022 12/18/2023 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 B MAA5021321-21 12/18/2022 12/18/2023 1,000,000 B CUA5021322-21 12/18/2022 12/18/2023 5,000,000 5,000,000 C N WC 9008270 12/18/2022 12/18/2023 1,000,000 1,000,000 1,000,000 Equipment Leased or Rented CPA5021320-21 12/18/2022 12/18/2023 Limit 80,000 Deductible 1,000 City of Salem 93 Washington Street Salem MA 01970 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms 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 endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 07/10/2023 Morse Insurance Agency, Inc. 285 Washington Street North Easton MA 02356 N. Del Sole (508) 238-0056 (508) 230-8367 chuckdelsole@morseins.com SIGNS BY J, INC. 100 TENEAN ST BOSTON MA 02122-3620 Union Insurance Company 25844 Acadia Insurance Company 31325 Selective Insurance Company of the Southeast 39926 22-23 A CPA5021320-21 12/18/2022 12/18/2023 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 B MAA5021321-21 12/18/2022 12/18/2023 1,000,000 B CUA5021322-21 12/18/2022 12/18/2023 5,000,000 5,000,000 C N WC 9008270 12/18/2022 12/18/2023 1,000,000 1,000,000 1,000,000 Equipment Leased or Rented CPA5021320-21 12/18/2022 12/18/2023 Limit 80,000 Deductible 1,000 City of Salem 93 Washington Street Salem MA 01970 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms 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 endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_________________________________________________ _ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. † Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ‡Contractors that check this box must attached an additional sheet showing the name of the 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. I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ 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 and/or 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:_________________________________ Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13. Other____________________ 1. I am a employer with _________ employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees. Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire, express or implied, oral or written.” An employer 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 house having 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.” MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.” Additionally, MGL chapter 152, §25C(7) 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) name(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 other than the members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents 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 of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on 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 applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under “Job Site Address” the applicant should write “all locations in ______(city or town).” A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant 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 dog 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 in 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 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 www.mass.gov/dia Revised 7-2019 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_________________________________________________ _ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. † Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ‡Contractors that check this box must attached an additional sheet showing the name of the 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. I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ 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 and/or 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:_________________________________ Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13. Other____________________ 1. I am a employer with _________ employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees. Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire, express or implied, oral or written.” An employer 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 house having 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.” MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.” Additionally, MGL chapter 152, §25C(7) 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) name(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 other than the members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents 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 of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on 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 applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under “Job Site Address” the applicant should write “all locations in ______(city or town).” A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant 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 dog 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 in 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 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 www.mass.gov/dia Revised 7-2019