11 CROSS ST - BUILDING PERMIT APP CITY OF SALEM
;a >r PUBLIC PROPRERTY
DEPARTMENT
%fl Hf IN :)Mlil.•'I I
�I st,st IY Wnstuns;1„�Slxurl' s SAt I'NI,M.u,.u.nl NI I IN 3197--
fiA: ')78-'ii95'l5 • ICsx. 978-74G9g46
Workers' Compensation Insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
\ ) )lieant Information /��" Please Print Leeiblv
N, nin : llluiuosyt]rl;annatinn)IndlN uluall: /q C C�\+Q�-
Adtlrcss: 1\ Ccoss Sol-
i?P�f�� IY yap ��S(S %'hone 0: 978-AS K10
:%re you an employer? Check the appropriate box: - 'Type of project (required):
1.❑ 1 am a employer with 4.fy l am a general contractor and 1 6. ❑ New construction
employees(full and,1ur part-tlnte).' / have hired the sub-contractors
listed on the attached sheet. ?.M Remodeling
2.❑ 1 and a sole[live
o proprietor o eespar H. ❑ Demolition
ship and have no employees
working for me in any capacity. %N' p. Insurance. 9. Q Building addition
INo workers'comp. insurance 5. ❑ We area corporation and its !0.❑ Electrical repairs or additions
required.] officers have exercised their
right orexenl tion per MGL I LE] plumbing repairs or additions
3.❑ 1 ant II homeowner doing all work c 5152, i 1(4),a nd w have no
myself. LNo workers' coop. 12.❑ Ruol'rcpairs
insurance required.) y employees- LNo workers' 13.0 Other
comp. insurance required.)
-env.pphcaut that d:ccks box at muss alas till out the aecuon Iw1uw,lowing their wurkus'cumpena:aiws pulicy intbrnwliun.
' I6bmalwmn rv'hu submit this aMdavit indicating they.ue doing all work and then him uutside cwuraewn must suhmil a new alfdavil indicting vueh.
4-onirwwn till check this box must atlachNd an additional nluxl ahuwiny the mane of tile sub-conrractors and Ihnr wurkcn'cwnp.policy mfomanun.
/ lin an employer that is pruvidfng workers'c•umpensntion insaruuc•e•fur sty employees. Below is the pulicy and job site
iufortnutiat. rtoj
I rsurancc Company Name: Ica U.�� ✓ Jx
Etepiralion Date:
Policy a ur Self-ins. Licc.. >_: ------
Job Size Address: 26 �`IL4(r'fttilS}� --. City;Slate/Ztp:taSa�bnMp'
Attach it copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
I:ailwc to secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up nI S1.500.00 and/or one-year imprisonment,as %Nell as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. Ile advi.scd that a copy of this statement may be Ibrwardcd to the 011ice of
larc>uga nuns of :hc DIA for inwoar.ce coNcragc \crilicauon.
/do berrhy c ratify Iu d p i s and penalties of perjury that the ioforaration provide// bb/uvvee is
true and correct
�i":Ian nrC: --- Daty. (�'� I
Oflicial use only. I)o not n•rite in this area, to be cutttpleted by city ur town aJjicial.
Cily or Town: ---- -- permit/License 0.- -_
is%uing Aulhurily (circle oue):
1. nl,ard of livallh 2. molding Mparunent 3. CitJ:"fonu Clerk 4. L•'lectrical Inspector 5, plumbing Inspector
6. Other -
Contact 1'cnotc --, _ Phoned:
e S
Information and Instructions
..\lassadluseus Gcncral Laws chapter I i2 requires all employers to provide workers' compensation for their employees.
Pursuaiu to this.,uture, an emplorre is defined As— every person in the service of another under any contract of hire,
c vpress or implied, oral or wr itten."
An employer a defined as"an individual, partnership, association,corporation or other legal entity, or any two or more
or the toreLoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
recei%er or trustee ul .m individual, pwincrahip, 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 an the grounds or building appurtenant.thereto shall not because of such employment tx-deemed to be an employer."
\IGL 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, IN IGL chapter 152, §25C(71 states"Neither the commonwealth nor any of its political subdivisions shall
anter into any contract for the pertomlance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
.applicants �
Phase rill 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 confinnation of insurance coverage. Also be sure to sign and dale the affidavit. The alfidavit should
be renmled 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 OfOcials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'laase be SurC to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicetse applications in any given year,need only submit one affidavit indicating current
policy int'ormation(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
townl." 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 tilled out each
year. Where a hume 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 bum leaves etc.)said person is NOT required to complete this of davit.
t he )I lice U[ Investigations would like to []lank )flu in advance fur your cooperation and should you lime any questions,
please du not hesitate to give us a call.
The D.:paronent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax q 617-727-7749
www.mass.gov/dia
d -
a
"i P i^ MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL
n APPLICATION FOR WORKERS'COMPENSATION INSURANCE
MAIL TO: The Workers'Compensation Rating&Inspection Bureau of Massachusetts
P.O.Box 55005 Boston, MA 02205
(617) 439-9030
IMPORTANT:
For assistance completing this applicall refer to the Pool Procedures for Now Applications under Residual Market on the B, u's wetsia,www.wcribma.mg.
A separate application must be flied for each legal entity. '
This application must be typed or printed in ink and submitted in duplicate to the Bureau.
Under no circumstance will coverage be assigned if: payment or required deposit does not accompany the application; the detllnation requirements are not met;
there Is a record of coverage in force for the entity making application; the applicant is in default of premium for prior workers'compensatlon coverage; or,
the applicant has an audit or inspection from a prior workers'compensation policy that remains incomplete due to the applieam's failure to cooperate with the prior insurer.
The earliest possible date coverage can be bound is at 12:01 A.M.the day after the application and required deposit are received in the rice of the Bureau.
The undersigned empmyer has failed to obtain workers'compensation and employers'Ilabiliry insurance in the voluntary market and hereby applies for such insurance
in the Massachusetts Assigned Risk Pool and expressly represents that such insurance is sought in good faith.
Requested
I. GENERAL INFORMATION
Effective Date: 09/16/08
1. Eric Chase DBA Chase Home Improvement
NAME OF EMPLOYER (Name the sole proprietor,general partner(s)or trustee(s)along with the trade name of the business.)
2. 04-3563667 ❑PENDING
FEDERAL EMPLOYERS IDENTIFICATION NUMBER (If pending,attach a copy of the IRS application.)
3. 11 Cross Street Bevedy MA 01915 978-265-4910
MAILINGADDRESS Number Street City State Zip Phone
4. 11 Crass Street Beverly MA 01915 978-265-4910
PRINCIPAL MA LOCATION Number Street city State Zip Phone
5. TOTAL NUMBER OF MA LOCATIONS
6. NONE
is ADDITIONAL MA LOCATION Number Street city State Zip Phone
(if there is more than one additional MA location,attach a list of street addresses and phone numbers. Fully complete Section VI for each location.)
7. 11 Cross Street Beverly Me 01915 978-265-4910
LOCATION OF RECORDS Number Street City State Zip Phone
8. LEGAL STATUS ® Sole Proprietor ❑ Partnership ❑ Corporation ❑ Trust ❑ Limited Partnership
❑ LLC ❑ LLP ❑ Other(explain)
If. ELIGIBILITY REQUIREMENTS
To be eligible to obtain assigned risk coverage:
• The employers application for voluntary Massachusetts workers'compensation coverage must have been rejected by two(2)carriers licensed to
write workers compensation in Massachusetts;
• The employer must not be in default of premium for Massachusetts workers'compensation Insurance;
• The employer must have complied with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety of employees;and,
• The employer must not have an audit or Inspection on a prior workers'compensation policy that remains incomplete due to the employer's failure to
cooperate wile the insurer.
1. List the names,representatives,dates)of discussion,and phone numbers of two insurance companies licensed to write workers'
compensation In Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named
must be an employee who has authority to bind coverage for the Insurance company. A failure to reach such a representative cannot be
construed as a refusal to write coverage.
ease
Travelers Ins - Amy Greely 09/15/2008 800-842-6762
The Hartford Colleen Denapole 09/15/2008 800-962-6170
NOTE: If coverage was recently terminated or expired in either the voluntary or assigned risk market,you must attach a copy of the cancellation or
nonrenewal notice. The reason for cancellation or nonrenewal must be indicated. If the coverage was in the voluntary market within the past sixty
days,the cancellation or nonrenewal will serve as one of the two required declinations. Generally,coverage must be.replaced In the voluntary
market if voluntary coverage was cancelled or non-renewed at the employers request.
2. Have you received any offers of voluntary coverage? ❑ YES ® NO
If YES,attach the offer for coverage,Including all multi-line,deductible,or retrospective rating terms.
3. is there any unpaid workers'compensation premium due from you or any other commonly owned enterprise? ❑ YES ® NO
If YES,provide the entity name,balance and policy number(s).
If the premium is being disputed,attach an explanation for Bureau consideration.
If an arrangement for payment has been made,attach a copy of the signed agreement.
4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy! ❑ YES ® NO
If YES,provide the name of the carrier and the policy number.
If the employer has scheduled an audit,provide the name and telephone number of a contact at the carrier.
EFFECTIVE JANUARY 29.2000-(EDITION 01)
Ill. rCORPORATE OFFICERS, SOLE PROPRIETORS, PARTNERS&MEMBERS
r
If there are more than four Officers,Partners or Members,attach a list including the required information for each additional individual
For Sop Proprietors.Partners.LLC Members and LIP Partners: List the Names,Titles,Ownership and Duties of all Proprietors,Partners or Members,and
Indicate whether each is electing coverage. Sole Proprietors,Partners and Members are not covered unless they elect coverage. To elect coverage,a letter
must be submitted on company letterhead in accordance with MA Regulation 452 CMR 8.07. Refer to the MA WC&EL Insurance Manual,to the Rates Page
with Miscellaneous Values,for Sole Proprietors',Partners'and Members'Basis of Premium. In Section VI,Include the Basis of Premium for all Sole Proprietors,
Partners and Members electing coverage.
For Corporations: List the Name,Title,Ownership,Duties and actual Salary of all officers listed in the Corporate Articles of Organization,and Indicate whether
each:has chosen to exempt himself from coverage in accordance with MA Regulation 452 CMR 8.06. Corporate officers will be included unless a Form 153 has
been submitted to and approved by the MA Department of Industrial Accidents. The stamped and approved Form 153 must be attached Corporate officer
salaries may be subject to payroll limitations;refer to the MA WC 8 EL Insurance Manual,Part One-Rule IX In Section VI,Include the salary,subject o the
minimums and maximums,of all nonexempt corporate officers.
Eric Chase Owner 100 Exempt mgt,sales, carpentry 30000
IV. INSURANCE RECORD
1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed Insurance company? ® YES ❑ NO
2. if YES,complete the following or the most recent three years:
Granite State 6803831 08/07/04 08/07/05 550
7
3. If NO,complete: ❑ New Business ❑ Uninsured ❑ Self Insurance Group ❑ Self Insured
❑ Other(explain):
4. Was the applicant self-insured within the last twelve months,or was the applicant's expiring policy subject to the ❑ YES ® NO
Premium Determination Endorsement—Former Self Insurers—1?
If YES,an audit must be completed before coverage can be bound.
Refer to the Pod Procedures for New Applications or details.
'Former members of Self Insurance Groups are:not subject to this endorsement.
If self Insured within the last twelve months,provide the termination date:
5. Is the employer in bankruptcy? If YES,attach a copy of the approved bankruptcy filing. ❑ YES ® NO
6. Does this entity or any other commonly owned entity have operations in states other than MA? ❑ YFS ® NO
If YES,attach a list of employer names,states,carriers and Interstate or Intrastate ID numbers.
7. Has there been a name change within the last five years? ❑ YFS ® NO
8. Has there been a merger or consolidation within the last five years? ❑ YFS ® NO
9. Has there been a sale,transfer or conveyance of ownership Interest within the last five years? ❑ YES ® NO
10. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they
I/ ' M
took over within the last five years? ❑ YES ® NO
11. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? ❑ YES ® NO
If the answer to 7,8,9,10 or 11 is YES,complete an ERM Form and attach it to this application.
V. BUSINESS OF EMPLOYER
1. Does the employer provide temporary or leased employees to other businesses? [:] YES ® NO
If YES,refer to the Pod Procedures or New Applications or Instructions.
2. Does the employer lease employees or regularly have temporary employees supplied to them from another business? [:] YES ® NO
If YES,refer to the Pool Procedures for New Applications or instructions.
3. MA Law provides that the employer is liable for injury of employees of uninsured subcontractors.
Premium will be charged In the absence of a certificate of Insurance from subcontractors.
Is It anticipated that subcontracted labor will be utilized during the policy tens? ❑ YEs ® NO
If YES,estimate payrolls made to subcontractors without certificates of Insurance. $
Transfer this amount to Section VI and Identify by classification of work performed.
4. Does the employer use Independent contractors? ® YFS ❑ NO
If YES,documentation must be maintained which supports that they are, in fact,independent contractors.
If such documentation is not available,or if the designated carrier finds evidence of an employment relationship,
then premium may be charged as if the individuals were employees.
EFFECTIVE) UMY 28,2008-(MTI0N 01)
v -
f `
V. BUSINESS OF EMPLOYER (continued)
5. Completely describe all operations of the employer. If there are multiple locations,provide a description for each.
Completely describe any changes that have taken place in the last three years that mi ht affect the classification of the operation.
[Interior carpentry. Finished carpentry,windows,doors etc.Most of the work is remodeling work. Work is residential In nature and done on bldgs 3
stories or less.
VI. MASSACHUSETTS CLASSIFICATIONS, ESTIMATED EXPOSURE AND PREMIUM CALCULATIONS
Attach the four most recently filed Form 9419 or.DET Form 19. Provide all information for each location by shift.
01 01 CARPENTRY-DWELLINGS 5651 2 2D000 7.50 1500
MANUAL PREMIUM 1500
Employers Liability-Limit Options(check one): • Waiver of Our Right To Recover From Others Charge
❑ 100/5D0/100 no charge A Employers Liability Increased Limits Charge( ) 0
❑ 100/100/1 000 .50% $75 minimum • Deductible Credit(-) 0
❑ 500/500/500 1 00% $50 minimum. • Experience Rating(-)or Merit Rating(-) 0
❑ 500/500/1,000 1.25% $75 minimum MCCPAP Adjustment( )
❑ 1,000/1 00011,000 2.00% $75 minimum STANDARD PREMIUM 1500
.. ........... ARAP(1 ) 0
QLMP Adjustment( )
' Balance to Admiralty/FELA Minimum Premium
• Loss Constant 0
VII. DEPOSIT REQUIRED: Expense Constant 338
_.......... _.. ---- —... ........ -- ...-..-...
1 Installment Options(check one) - Terrorism Premium(Total Payroll/100 x 0.03) 6
Installment Required Total Deposit Additional
—__Faclgu__ • Balance to Total Policy Minimum Premium
__.__-Pakm_ents -.
❑ Annually a $0 100% none '• Former Self Insurers Insurance Charge
❑ Semi-Annually > $5,000 75% one TOTAL ESTIMATED PREMIUM
❑ Quanedy a $10,000 50% three DIA Assessment(6.3%) 95
❑ Monthly > $25,000 25% nine TOTAL EST.PREMIUM AND DIA ASSESSMENT 1939
..._ _._.-...-.._ ---._.._..._-__.—.._.._ . . ...
••' REQUIRED DEPOSIT 0
2. Enclosed is check number 1799 in the amount of $ 1939
Make the check payable to the Massachusetts Workers'Compensation Assigned Risk Pool(or'MWCARP').
3. Any binding of coverage is conditional until the check has cleared. If the check is found to be non-negotiable,the check will be returned to
the employer who will be given ten(10)days to provide the Carrier with a bank check or money order for the full amount of the required
deposit. Only if sufficient funds are received by the carver on a timely basis,will coverage be effective as of the tentative binding date on the
Notice of Assignment Issued by the Bureau.
4. Is the premium being financed? ❑ YES ® NO
If YES, then 100%of the Total Est. Premium and CIA Assessment must be sent with the application along with a signed copy of the finance
agreement.
if applicable. Refer to the Pod Procedures for New Applications and to the Residual Market Premium Algorithm—Appendix F in the MA Manual for details.
.. Applies only to Former Self Insurers. Refer to the Pool Procedures for New Applications for details.
»• Calculation of Required Deposit:
(((Total Est.Premium+DIA)—(Expense Constant+Insurance Charge))x Deposit Factor)+(Expense Constant+ Insurance Charge)
EFFECTIVE JANUARY 28,M)II-(EDITION 81)
00
Vlll.APPLICANTS AGREEMENT—PLEASE READ CAREFULLY
By signing this application,I certify that:
(1) 1 am the employer a have been authorized by the employer to complete this application on its behalf;
(il) I have read and understand the following statements to which I agree by signing this application;and
(III) All Information provided in this application and on its attachments is true.
In consideration of the Issuance of a Notice of Assignment and subsequent policy of Insurance,I hereby certify,under the pains and
penaltles of perjury,that:
1. I made a good faith effort,but failed to obtain coverage through the voluntary MA workers'compensation insurance market;
2. 1 am not knowingly In default of premium on any MA workers'compensation insurance policy;
3. 1 have complied and will continue to comply with all laws,orders,rules and regulations in force and effect relating to the welfare,health
and safety of employees,including but not limited to:
a. Allowing the carrier to make a careful inspection of my operation for the purpose of measuring the hazards,making
recommendations for the health and safety of employees,and determining the rate or rates which are adequate and reasonable;
b. Complying with the carriers'reasonable recommendations aimed at controlling or reducing the hazard(s)insured against;
c. Keeping records of information needed to compute premium and providing the carrier with copies of Hose records when
asked for them;and
d. Fully cooperating with the carriers'attempts to conduct premium audits or inspections of the premises for loss control purposes.
I understand that the employer's compliance with each of these certMleaN b to the Issuance of Assigned Risk Pod coverage.
Era ckost_ D13A C.I1vs t
cl
Business Name of Employer Date Signature and Title Sole Proprietor,General Partner!Ca rate Officer,Trustee or Member)
Th insurance is being provided through the MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through
the voluntary market. The employer's noncompliance with certifications 1,2 and 3(a—d)may,to the extent allowed by Massachusetts law,
cause the carrier to Initiate a mid-tens cancellation.
FRAUD NOTICE:
Massachusetts General Law,Chapter 152,Section 14(3)provides:
"(A)ny person who knowingly makes any false or misleading statement, representation or submission or knowingly assists,abets, solicits or
conspires in the making of any false or misleading statement, representation or submission,. or knowingly conceals or falls to disclose
knowledge of the occurrence of any event affecting the payment, coverage or other benefit for the purpose of obtaining;or denying any
payment,coverage or other benefit under this chapter, and any person or employer who knowingly misclassifies employees or engages in
deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...shall be punished by imprisonment In
the state prison for.not more than five years or by Imprisonment In jail for not less than sac months car more than,two and one-halt years or by
a fine of not less than one thousand nor more than ten thousand dollars,or by both such fine and imprisonment"
IX. AGENCY INFORMATION AND PRODUCER'S STATEMENT
The producer hereby certifies,under the pains and penalties of perjury,that all information provided to true to the best of Mother
knowledge and belief and that he/she made a good faith effort to place the coverage In the voluntary market as required by
M.G.L.,c.152,Section 65A. / 1� A a
AGENCY J-06k J WRIS`rt -XAJ ttCLrtM._ Tii� Vg30e180 1
��tName(Printed) ryry �'+ (/ 'MM Agency Federal Identification Number
ADDRESS T/7 MDI/Att. Jc D&ur't Irk 6141.10 97,374S-3-?(30
Street
-{,City /� State
QZip Code ply. Telephone
PRODUCX6 �2TfQ,YLCOUy f 1 I.W L1Q � —IL'oe ��OfJ ��
Name(Printed) Slgna re ` Date Agency Uoense Number
MASSACHh SETTS WORKERS'COMPENSATION ASSIGNED RISK POOL
ADDITIONAL INSTRUCTIONS
PLEASE READ CAREFULLY
1. Pool Procedures for New Applications and for Existing Policies can be found in the Residual Market area of the Bureau's website,www.wcribma.org.
2. Applications will not be accepted by FAX machine.
3. An additional or replacement entity cannot be endorsed onto an existing assigned risk policy as a named insured unless an application and check are
submitted and coverage is assigned by the Bureau. Refer to the Pool Procedures for New Applications for instructions.
4. The Pool is able to provide coverage only for MA employees. If an employer has operations in any slaw other than MA,or commences operations in
such state after policy Inception,application for coverage for those operations must be made to the appropriate Bureau or other agency administering
the Residual Market In that state,If voluntary coverage is not available.
5. When a Pool policy has been cancelled twice by the Insurer or nonpayment of premium,the employer will lose his payment plan,and payment In full of
the remaining policy premium will be required as a condition of reinstatement.
6. When a Pool policy has been cancelled twice at the request of the employer,the producer of record or the finance company,the employer must
reapply to the Pool or subsequent coverage after all outstanding balances have been paid.
7. Applications for Joint ventures must Include a copy of the joint venture agreement.
8. Payrolls and classifications are subject to review by Bureau Staff and may be changed.
9. The Waiver of Our Rights to Recover from Others Endorsement,WC000313,is available to employers who require the endorsement by contract.
Refer to the Pool Procedures for New Applications or details.
10. Producers are not agents of the MA Workers'Compensation Assigned Risk Pool and cannot Issue Certificates of Insurance.
11. If you have any questions about the rules governing the MA Workers'Compensation Assigned Risk Pool,refer to the Bureau's website,
www.wcrlbma.org. If additional inormadon Is required,contact the Workers'Compensation Rating&Inspection Bureau of MA at
(617)430.9030 or write to either P.O.Box 55005;Boston,MA 02205 or 101 Arch Street,Boston,MA 02110.
EFFECnWJANW n.2X4-(EDM0N0m
HODGES COURT.REAL&SPATE LLC , 1799
ANDREW STREET RItOj6C"T HISTORIC SALEM
100
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