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10 JEFFERSON AVE - BUILDING INSPECTION (2) •�auS-cL�rc� �p!� .� � The Commonwealth of Massachusetts Y�1Y' �yy Department of Public Safety }` J. \Lusac husclls State Building Qule(781)C\I R) Building Permit Application for any Building other than a One-or Lwo-Family Dwelling (I"his Section For Official Use Only) Bu ilt it Per mit Nuntbec Date:\pplicd: Building Official: SECTION 1: LOCATION(Please indicate Block Nand Lot p for locations for which a street address is not available) No.and Street City/town Zip Code Name of Building(if.applicable) SECTION 2:PROPOSED WORK _ Fdiiion of MA State Code used If New Construction check here❑or check all that apply in the two rnw:s below fsisling Building❑ Repair❑ :\Iteration ❑ Addition❑ Demolition ❑ (Pipase till out and submit:\pprnd ix I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Arc building plans and/or cunslntclion d,w'umenls being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review Bret uire 17 Yes ❑ No ❑ Brief Description of Proposed Work. �0(����__ — SECTION 3:CONIPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,AUDITION,OR CHANGE IN USE OR OCCUPANCY Check hem if an Existing Building Investigation and Evaluation is enclosed(See 780 C\IR.1-f) ❑ Exisling Use Group(s): Proposed Use Group(s):__ SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed Nu.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-i❑ I B: Business ❑ I. Educational ❑ 17: Facto F-I ❑ F2❑ fl: Hi h Hazard H-1 ❑ H-2❑ il-1 ❑ II-4❑ 1-1-5❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ \I: Alercantile❑ It: Residential R-I❑ R-'_❑ R-3❑ R-4❑ S: Storage 5-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use SECTION 6:CONSTRUCTION"IYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VIi ❑ SEC"TION 7:SITE INFORNIIA"rION(refer to 780 C\IR 111.0 for details on each item) Water Su ppiy: PIouJ Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public❑ Chock if outside hood Zone❑ Indicate municipal ClA tnvtch will not be Licensed Disposal Site❑ I'm Me❑ ,or mklcnlify lone: -- or on site st Wm ❑e required ❑or trench or specify: . permit is enclosed ❑ _ - Railroad right-of-way: Ha/arils In Air Navigation: \I \ i,; ,., .�.. ... . . .. . ,. Not Applic.ibly o Is Sim,[tire within airport approerh area.' Is ihrir rev icw com plcird' ur Convent to Butd encluse.I ❑ I1 vs ❑ or.No❑ Yes Cl No ❑ SI:C"IION 8:CON'I EN OF CI.RTIFICA'FE 01:OCCUPANCY I!dilium of Cade: .- ... 1\e Group(.): - - . - I\pool Gonslrwlion: tlrnq+enl Load per 1:1....r. D,�es ihr building;i��n lain,m>prin6ler tieslrmL tiprri,il<lipulalions: (PC, �6� o� �►e� SI(CI'ION 4: 1'ROITR'I'Y OWNFR AU'I'IIORIZA"IION \'aunt,uxl Address ut I'n gn•rty Uw'nrr -- '_ - -(0 s ,01- --- Name(Print) No. and Street City/Town Zip Property Owner Contact Information: v4/{;r 00CIF r �� 17? -4LL- to 40 title Pclephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip — lo act on the property owner's behalf, in all matters relative to work authorized b - this building tennit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) if buildin•is less than 35,000 cm ft.of enclosed s pace and or not under Constriction Control then check here D:md skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control Na to(Registrant) Telephone No. e-mail,uI I c• Registration Number Street Address / Cit / own Ste Zip Discipline Expiration Date if 1 l 10.2 General Contract r Company Name Nome of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Tole phone No. business Telephone No. [ell e-mail address SECTION 11:tttn:f.la::• rni,xu•rV.arup.\ i,v"ur..\\c'r.vrn ll M.G.L.c.152.§25C6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yes❑ No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and \laterials) Total Construction Cost(front Item 6)=S 1. Building S Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical S appropriate municipal factor)=5 3. Plumbing $ J. Mechanical (Fi V:\C) $ Note: \lininnun fee =$ _(Contact numicipah ) i. Mechanical Other $ �— Fnclusc iheik payable to Total Cost 5 (Contact nmt n ici pa l ity)and write Check number here _ sF( I-For4 13:SIGNATURE OF BUILDIr$GpER11,IIT APP (CANT 14v entering or' name below, I he •py attest wader the pains,and penah'•s of erjury Ihat. I of the information cont.iineJ in this npl Ration is true and accurate o the best Of Illy knowledge and undo standii g. ! Pleas, print and sign name -Ile telephone N, Date tilrcet .\ddress City/ I'Pwlt State Zip Municipal Inspector to fill out this section upon application approval: - Name ILte 1'�- FM HOME IMPROVEMENT CONTRACTOR Registration: 170037 Type: Expiration 911/2013 Individual RBL�/HOXHAJ - 7J ARBEN HOXHAJ 11 CENTRAL ST BEVERLY, MA 01915 , Undersecretary ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDYYYY) 03/21/2012 PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.NAUTILUS INS CO. Arben Hoxhaj Ben the Mason INSURER B: 11 Central St Apt 2 Left INSURERC. INSURER 0: 113everly MA 01915- 1 INSURERS COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE(MWDD/YY) DATE(MM/DDNY) LIMITS a GENERAL LIABILITY NN140187 06/14/2011 06/14/2012 EACH OCCURRENCE $ 1,000,00( X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50r00( PREMISES Ea occurrence $ CLAIMS MADE F—IOCCUR / / / / MEO EXP(Any one person) $ 5,00( PERSONAL&ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,00( POLICY JECTPRO- LOC / / / / NO AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) $ , HIREDAUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per awdent) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELIA LIABILITY / / / / EACH OCCURRENCE Is OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND / / / / TORT LIMITS OTH EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EJ(ECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ If yes,describe under -- SPECIAL PROVISIONS balm E.L.DISEASE-POLICY LIMIT $ OTHER DESORIPTON OF OPERATIONSILOCATIONS EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT)SPECIAL PROVISIONS JOB SITE: 10 JEFFERSON AVE SALEM, MA. 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT MOFFATT REALTY TRUST FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE PO BOX 108 INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPR TI SALEM MA 01970- _ ACORD 25(2001/08) - OACORD CORPORATION 198E q7'1-INS025(0108).05 ELECTRONIC LASER FORMS.INC.-(800)327-, Page t of; /vN MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL 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 application,referto the Pool Procedures for New Applications under Residual Market on the Bureau's website,www.wcribma.org. A separate application must be filed 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 declination 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'compensation coverage; or, the applicant has an audit or inspection from a prior workers'compensation policy that remains incomplete due to the applicant'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 office of the Bureau. The undersigned employer has failed to obtain workers'compensation and employers'liability 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: 03/21/12 1. BEN THE MASON NAME OF EMPLOY R (Name the sole proprietor,general artner(s)or trustees)along with the trade name of the business.) 2, _ _6--3 f,q a ` -�o ❑PENDING FEDERAL EMPLOYERS IDENTIFICATION NUMBER (If pending,attach a copy of the IRS application.) 3. 11 CENTRAL ST.#2 LEFT BEVERLY MA 01915 978-408-1392 MAILING ADDRESS Number Street City State Zip Phone 4. 11 CENTRAL ST.#2 LEFT BEVERLY MA 01915 978-408 1392 PRINCIPAL MA LOCATION Number Street City State Zip Phone 5. TOTAL NUMBER OF MA LOCATIONS 1 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 CENTRAL ST.#2 LEFT BEVERLY MA 01915 978 408 1392 LOCATION OF RECORDS Number Street City State Zip Phone 8. LEGAL STATUS ® Sale Proprietor ❑ Partnership ❑ Corporation ❑ Trust ❑ Limited Partnership ❑ LLC ❑ LLP ❑ Other(explain) II. ELIGIBILITY REQUIREMENTS To be eligible to obtain assigned risk coverage: • The employer's 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 with the insurer. 1. List the names, representatives,date(s)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. WIT'::'tF¢) EC' Q �, �,�;T:(,. -. ZURICH GENA OLLENDICK 3/21/12 800-800-3907 HARTFORD BARBARA LOBDELL 3/21/12 800-742-6363 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 employer's 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. ((tt t. i, C EFFECTIVE JPNUARY JP Jnnn.mnni... •.• III. CORPORATE 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 Sole Proorietors Partners LLC Members and LLP Partners List the Names,Titles,Ownership and Duties of all Proprietors,Partners or Members,and ' mdlcate 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 maybe subject to payroll limitations;refer to the MA WC&EL Insurance Manual,Part One-Rule IX. In Section VI,include the salary,subject to the minimums and maximums,of all nonexempt corporate officers. *" Alli ;; E r > -%OWNERSHIP' ELECT/EXEMPT;;, DUTIES ARBEN 100 i=' '�' SA@ARYt;, .t EXEMPT MASON 20000 IV. INSURANCE RECORD i. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? ❑ YES 2. If YES,complete the following for the most recent three years: ® NO r 4INSURANCE�COM ANY - P YxI POLICYNUM`ER POLICY PERIODx i; f+ 1... :,, t ..dye? FROM i' r:1d.� TOt; Y PREMIUM x* 3. If NO, complete: El New Business ❑Uninsured ❑Self Insurance Group ❑Self Insured ®Other(explain): MAY HIRE EMPLOYEES 4. Was the applicant self-insured within the last twelve months, or was the applicant's expiring policy subject to the Premium Determination Endorsement—Former Self Insurers—19 ❑ YES NO If YES,an audit must be completed before coverage can be bound. Refer to the Pool Procedures for New Applications for 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? If YES,attach a list of employer names,states,carriers and interstate or intrastate ID numbers. ❑ YES NO 7, Has there been a name change within the last five years? 8. Has there been a merger or consolidation within the last five years? ❑ YES ® NO El YES ® NO 9. Has there been a sale,transfer or conveyance of ownership interest within the last five years? 10, Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they ❑YES ® NO 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 If the answer to 7, 8, 9, 10 or 11 is YES, complete an ERM Form and attach it to this application. ® NO V. BUSINESS OF EMPLOYER 1. Does the employer provide temporary or leased employees to other businesses? If YES, refer to the Pool Procedures for New Applications for instructions. ❑YES ® NO 2. Does the employer lease employees or regularly have temporary employees supplied to them from another business? If YES, refer to the Pool Procedures for New Applications for instructions. ❑ YES ® NO 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 term? If YES,estimate payrolls made to subcontractors without certificates of insurance. $ ❑YES ® NO Transfer this amount to Section VI and identify by classification of work performed. 4. Does the employer use independent contractors? If YES,documentation must be maintained which supports that they are, in fact, independent contractors. ❑ YES NO 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 emp loyees. oyees. EFFECTIVE NNOARY 28,2008 (EDITION 01) V. BUSINESS OF EMPLOYER (continued) 5. Completely describe all operations of the employer. If there are multiple locations, provide a description for each. Completel describe an changes that have taken place in the last three years that might affect the classification of the operation. MOSTLY RESIDENTIAL MASONRY VI. MASSACHUSETTS CLASSIFICATIONS, ESTIMATED EXPOSURE AND PREMIUM CALCULATIONS Attach the four most recently filed Form 941s or DET Form is. Provide all information for each location by shift. Lowtloo# Shlftp;^ Describe Class: . Numbs Of . Estimd ,Oe y 'Code JEmoe , E -..; oaure ' Rrhe ,x Preinlum 1 i MASONRY NOC 5022 1 1800 10.55 190 ' MANUAL PREMIUM 190 Employers Liability Limit Options(check one _ .,. ) Waiver of Our Right To Recover From Others Charge ® 100/100/500 no charge Employers Liability Increased Limits Charge( ) 0 ❑ 100/100/1,o00 50% $75 minimum • Deductible Credit(-) p ❑ 500/500/500 1.00% $50 minimum Experience Rating(-)or Merit Rating(-) 0 ❑ 500/50011,000 1.25% $75 minimum MCCPAP Adjustment( ) ❑ 1,000/1,000/1,000 2.00% $75 minimum STANDARD PREMIUM 190 ' ARAP( 1 ) 0 QLMP Adjustment( ) ' Balance to Admiralty/FELA Minimum Premium " Loss Constant 50 VII. DEPOSIT REQUIRED : Expense Constant 159 1. Installment Options(check one): • Terrorism Premium(Total Payroll/100 x 0.03) 1 Installment Required Total Deposit Additional „-_Basis Est Premium Factor _ Payments _ Balance to Total Policy Minimum Premium ® Annually > $0 100% none...._ ...._ -_. _ ' Former Self Insurers Insurance Charge ❑ Semi-Annually > $5000 75% one -- - -- ----- TOTAL ESTIMATED PREMIUM Quarterly > $10 000 50% three DIA Assessment(5.9%) 11 ❑ Monthly. > $25 000 25% nine TOTAL EST, PREMIUM AND DIA ASSESSMENT 512 REQUIRED DEPOSIT 512 2. Enclosed is check number 229 in the amount of $ 512 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 carrier 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 DIA Assessment must be sent with the application along with a signed copy of the finance agreement. • If applicable. Refer to the Pool Procedures for New Applications and to the Residual Market Premium Algorithm—Appendix Fin 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) I EFFECTIVE JANUARY 28,2008�(EDI➢ON 01) E •p. Vill. APPLICANT'S AGREEMENT—PLEASE READ CAREFULLY @ By signing this application, I certify that: (i) I am the employer or have been authorized by the employer to complete this application on its behalf;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. t In consideration of the issuance of a Notice of Assignment and subsequent policy of insurance,1 hereby certify, under the pains and penalties 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 those 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 certifications' material tot i u nce of Assigned Risk Pool coverage. 1 Business Name of Employer Date Signature and Tire ole ropnetor,General nner,Corporate Officer,Trustee or Member) NOTICE: This insurance is being provided through the MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through the voluntary market. The employer's non-compliance with certifications 1, 2 and 3(a—d)may, to the extent allowed by Massachusetts law, cause the carrier to initiate a mid-term 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 fails 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 six months nor more than two and one-half 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 is true to the best of his/her 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. AGENCY CLEMENT C.ARCHER INSURANCE AGENCY, INC. Name(Printed) 042658798 Agency Federal Identification Number ADDRESS Street CABOT ST. BEVERLY MA 01915 Street -922-4600 City State .p Co 97 Telephone Telephone PRODUCER NEAL HUTCHINS � Z / l Name(Printed) a r Date [_ 1780915 Agency license Number MASSACHUSETTS 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 state other than MA,or commences operations in such slate 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 for 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 for subsequent coverage after all outstanding balances have been paid. 7. Applications forjoint ventures must include a copy of thejoint 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 for 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.wcnbma.org. If additional information is required,contact the Workers'Compensation Rating 8 Inspection Bureau of MA at (617)439-9030 or write to either P.O. Box 55005,Boston, MA 02205 or 101 Arch Street,Boston,MA 02110, EFFECTIVE JANUARY 18.2008-(EDITION 01) t i Jr f iF! yen S'3z•^. .,'^^z- h'ARBEN HOXHOJ 07-08N' � P`( +� ALMA HOXHAJ 15 KENMAR DR. 229 NO. 17 BILLERICA,MA 01821-4708 7! 53-13/110 MA 82696 Poy to the ,lj' JC Date Order of J a33an'41i+t,r90tl9+JCip,,j �6o1%rs 8' ACH q/r 011000138 A. 1:0 1 1000 1 381: 0046 20 268 27 311'0 2 29 wwecu.