24D-231 .zauotssiuuuo3 2uippng — Ionoigsm smog
ZLZI (£ib) : `0tZt-L8S (£tb) auogd `13011S U AI ZJZ
00'081$ 00:00:0 0t0Z /S /11 $uipIJna
:3unoiuy :Ned alua :adAZaaj
:ain;nusls Aouedno30lo eieO!JflJOO
•SUOISVrIn0DDI aNY sawn' SII IO AAIV
.IO l�IOI,L�'IOIA AIOdn AO AIIO alit AS GINOAHH all AVVI IIwaad SIHI
:Inul :amouis :Inul
:uoi;ntnsuI :ITOO :q�nog
:4fauu /aanidaam ;uauu;.[nnaa a.0 :sup
:annul Onog
:Inu13 :Inuu
:Ieut3 SEAtanlJQ
:uol ;npuno3 # asnoH :Onog
:s2ul;ood
:Ja;ayv :aaptias :punoa2iapun
ao ;aadsuI 2uipling •M•d•Q 2ula1M jo .io ;aadsuI Juigwntd jo ao ;aadsuI
L D L1S i'IfISIA SI II OS a2IV0 SIHI ISOd
dSNI
H92I 2 03 1A1 a33N - N3HIIN - 13CIOINal:XZWAI JAIIA107701 !H.L hXOd?Ifd O.L
00:00:0 orous/IIwo agi1SSI Z9060VW30N32JO13
6Z66 (£ I t7) U I NO1dJAIVHISHM t7051
:ad umnsul :auoyd : ssa rppd ?uvn ,ddv
IS 103dSO Id OZZ :IV
SNIM3H 13INVa :Junolladd /(00T)Enin :miuoz
2IgGIHNH3S a 3NRIHHIV)I 2 S 1 I QIAVU NVI'1010 :Jaunlp 08'Z999 :('13 'bs)aziS;n'I
� 6L6t70 SNIM3H 13INva :anoJO asn
:asuaat7 :Jopv quo3 :ssn10 Isuo3
:01 Q2.LAIV?tL M L fl UH SI ANOISSII 2fd 00'081$ :
00'0000£$ :3s • ;sg
Z69000 60Z-s # 13alo.1
E3v0- I. I.0Z-d8 # i uuad
ZIIARI�d DMIQrIIllI :A.loWaluj
(vZ14'o 10W) aNl3 AINV NfO 3H1 OI SS300V 3AVH ION Oa bu!pI!n8 :puuad
SUIOIDV'LLNOD Qg2IgLSIJfl2INn HIIM JNLLDVII.LNO3 SNOSSIgd 100 :;n'I
NO1dLAIVHZ210I1I AO A,113 1U x ,
silasfl ovssvIAT ,IO H IVaMuo TA10a :# SID
£Zt 6 603 -d8
•uoiiEu.uojut aioui ioj IuauudoianaU a8 2uTuuuid
jo aotijo ioEiuo3 . dub 'IDJAJjo spi puEis iouis 3111100M ogm siuuotiddE asogi of Aim paiurs2 aiE saouBi1EA *
•sai;uoq ;nu tut;uua3;iwiad aiquatiddu aaq ;o pun s po,n aggnd jo
;uaw ;audac'uoissnuwo3 uoi;unaasuoD'q ;ivag jo piuog woa3 sitw.tad pa twba i iiu utu;go puu s;uaumunbaa
2uiuoz iiu wit ,fidwoa o; uapinq sjuuapddu u anapaa jou swop wand 2uiuoZ u jo aauunssl :aioN
aiuQ
imam 8UTp map a1n2EU5JS
( —5-7, 001111111. ..,1111•3 •
'iEiaU uotitiouna
ivautaBuuuN JaiuM uUOis MdU iluuad - uotsstuzwoJ pails wig UJO.g iPU1.iad
aaiinuwo3 aanioaitgozd g0 U1O13 4Tuz.Tad uotssT 11UTOO 110g1Enias1103 11.10.13 inTUad
giivaH3o p't?og ititiiquiod .zaiuM ii°M giivaH JO preog iunoiddd oiidaS
,CitiigEJT Ay .iamS AitiiquipEnd mum Mdi wog lop giro
:pagnba21 Situuad Jai0
pasoioug paid spaaQ JO X.TiSI O)J iu pap1OOaJ 2g pani3o021
* aouuuEA i?w -tad iuioadS 2uiput3
§ :2IaaNf1 Qa2IIfiag2I iimaa Q2IVOg ONINOZ
uEid ai ?S IIIIM11uuod iutoadS 110 /QNV mid NIS :1O3 fo.id zofJ,
mid aNIS 11'M i?L' -' d iu!OadS 2I0 /QNV uuid NIS :3OaMO1d aiutpauuaiui
§ ?IaQNII Qa2ILC1a iu ,LIIARIad (I2IvOg ONINNV'Id
(moiaq aas) paimbai situuad iuuotitppd panoiddd
:aaiNasalm NOI.LV. NI
NO QaSVf NOIINDI'IddV SIHI MO N NVI NUII SVH NOIIOV ONIMO'I 3 MIL
uuid lOid / Suutd 3o sias £
17JL6170 asuaori zo ivawaiu2S /.zaum0
:papnioui souk' wuTpimg
am4OnuS ntossaood
u sTXg Oi uogtppt,
suoT1Enoual io1.iaiut JEmioiuis uom
� S r uopol isuo3 maid
• ` ! ( cg „ ` G` Ce !Yea a lr; C f, 7 n N3H0 LI?I " I3QOY�i32I :uoiion.Tisuo3 3oactti1
�-
off J A M Pred 33 3
ino PNIT3 it "°d zuipitng
PTEd 304
ZflO QgTII3 IARIOd DNINOZ
11VQ amnbff I Q3so'IDN3
ZSIT}IDRHD NOIIVDI1ddd lIIAfigd
�I INO gSfl 'IVIDI330 2103 NOIID S SIHI
/(00T)EDIfl gNOZ TOO 1£Z 11DaIHd QbZ dVY\i
IS IDadS02Id OZZ NOI.LV3O1 AI lad02Id
6Z66 (£ It) aDmaliou WI NO1dINVHISHM iOSI 3NOHd/SS32IQQV
SNIMgH "I3INVQ NOSuad IDVINOO /.LNVJI'Iddd
£Zb0 IOZ # ait3
oleo s6u!ppng ;o JopedsuI /Jauo!ss!wwoO 6wp!mg
:a.tn;eu6!S
:perms! :JegwnN ;luuad 6u!pl!ng
oleo
Also asn !ammo J03 uogaas s141
4 7 2 3 1 l : J JegwnN pago
OD* � ("C ( 9 + + + Z + = ' 9
N uopelatd a.nd '9
(OVAH) leo!uegoalN 'b
L
eaA *wad 6ulpl!n9 O° 5 Z 6u!gwnld •E
(9) wail uoi}onJ;suo0 LL
�0 lso0 lelol pelew! ;s3 (q) 00 7 Z leouloal3 Z
S
ae.d ;!weed 6uippng (e) O 0 O 6u!PI!ng • l
;ueo!ldde wined peleidwoo
i(lup esn le!oU40 aq oa (s.telloa) ;so0 pe ew!ls3 wa ;l
81903 NOIl311211SNO3 031VINI1S3 - £ NOI103S
euoydeial aJnle4s
bzbb 'Z 5 v\i4
:ssejppy 61.1ipe!ry ;uaJJn3 (luud) aweN
'42l ric1o<oeHJ -5 3m fio$ I Sri t,A? ii 1 5I r /Q
:;uabV peZIJo ;ny Z•Z
A r euoydelal
A L E. L h6 5 :sseJppd 6uiliew ;ua.un3 ` (luud) aweN
F'Vv'"o1 3i`9Q .1j(1l9r ADO(
:pJo3a 4 0 JeuM 6•Z
1N3DV a3ZINOH1fV /dIHSa3NMO Al213d0Hd - Z NO1133S
;ou ;s!a 80 ;3!4$!a 3S wl3
;a!J ;sla AepeAO auoZ 1,
Pun ;0l deyll 5 .L 7 4 S 0 ZI d 0 Z
eati10 Aq pe ;e dwoo aq o; uonoes sm.!. :ssaippV iyaaaoJd l 1
NOIIVINNOINI 311S - 6 NOI133S
ONI113M0 AIIWV1 OMl a0 3N0 V HSIlOW3a so 31VAON3d `21IVd321 `21311V `10naISNOO Ol NOIIV01'1ddV
y!oadS i9410
sueId ai!SR01d ZLZ 6 6i/ Xed OVZ 6 6ji euoyd
stin Iemaan.gS ;o s;aS onnl 0901.0 VW `uOjdwey4loN
lI!l!gel!enV IIaM/ialeM 00 6 W OO f �?
*!gelleny o! ;dagpemaS lee- uleW Z 6Z
;!uuad Aemenpaftn0 qm0 luaw):1edea 6uipIin8
: ;!wJad ;o sn ;e ;S UO4dwey),ION JO '4!O
Apo esn ;uew}tedea
.pannbaJ sl Mdd ay; wall Pulled ;uawa6eueiN ialeM uuo ;S uo ;dweyuoN e uay; 'S3A di
Q ON Q S3A L9Joe 6 19n0 qJn ;sip !um ley;
ueid uowwoo a ;o ped sl Jo aloe nano (6wlig Jo `uogeneoxa `6uwpei6 `6uueap) ci nnslp Il ;!Aloe uolpnj ;suoo ay; Il!M .3
:uol ;eDo) pue ads(; `azls agtDsap `s3A 31
Q ON Q S3A c Aliadojd ay; Jo; papua ;ul suds jo suol ;lppe Jo o; saSuegD pasodoad Aue aiay; any •a
:uol ;eJoi pue ads(; `azls aquDsap `53A 31
Q ON Q s3A uo ;slxa suds i(ue oQ
:panssl oleo ` Q paule;gp Q paule ;qo aq o; spaaN
zuotsslwwoj uou emasuop ay; woJ j paule;go aq o; paau Jo uaaq ;luuad e seq `s3A 31
Q s3A Q MON)1 LNOa Q ON zspue) ;aM JO ialenn Jo Apoq `Nooiq a ule;uoJ a ;ls ay; saoa •g
#;uawnJOQ Joipue a8ed )loog Ja;ua :53A di
Q S3A Q MON)i .LNOQ Q ON
ispaaa jo ti;sl8aa ay; ;e papioaai ;lwjad ay; seM :5314 31
:panssl a;ep `s3A 31
Q S3A Q MON)i ,LNOQ Q ON
�a ;ls ay; UO /JOJ panssl uaaq Jana 8ulpul3/aJUeueA/;u.uJad ieLJads e seH •y
(uouicaoli ag awnion)
:li!d
saoeds 2upped Jo #
(dui pi d
paned ag 2piq snuiw ease lo'1)
a5e;oo3 coeds uadO
o5e;ood arenbs '2plg
VISPH OutpIing
.teak
:21 :"I :2I : ( ap!S
;uoi3 sveq;as
azts ;og
luauaedaU dwpung
tq ui pang aq o1 =moo sigl
; uluoz ,(q pannbag pasodoad Wut ;S!xg
uoneuuo;ui alaidwoDui of and paivaa ag imp mniad •palaldwoD al] Ism uoneuuo;uI By ONINOZ i not Jas
eiea =Jam° }o eJnleu6ig
—
Or 1 I fr. \
aweN luud
SrtlMRK 731 rt 51(1.
.tinflad ;o sa!lleuad pue sued ay} Japun pau6!S
1a!laq pue
a6palnnouNl Aw jo }sag ay} 01 'a }eJnooe pue awl ate uo!leo!ldde 6u!o6aJo; ay} uo uo!lewJo }u! pue s }ua ale }s ay} 1ey1 areloap � qe ay }41.196V pezuoylnV /JauM0 se ' S, (M N l 1 3 1 ( Z '1
ole7
,, !.� .11 .fir
. uogeo!ldde }!wJad 6wplmq s! Aggpe , ow 1 an! - sJal}ew lle u! ' ;le % /0210 •
/� 7 ,�[ = oylne Agway
�(
11A 3 I 1 11 1 V Q Apadwd
loafgns a43 ;o JaunnO se ' f ..1 3 r 'V ct 434131 ,k L S i
1IW213d ONlalifl8 H01 S3I1ddV 21010V211N00 2I01N3OV S213NM0
N3HM a3131dW03 38 01 NOIIVZRIOHIf1V 213NMO - eL N011339
Aiddns Ja }eM Al!0 119M a }enud Jamas A1!a Nue1 o! }dog . I
• oN saA 6suo!4eln6aJ 6u!uoz pue 6u!pl!ng ayl 01 wJoluoo 6u!pl!nq II!M . )I
epe.i6 pays!ug Moleq ioo6 Jeneo Jo luawaseq to yldaa . f
oN sa) u!eldpoog Jr( pp. Wl}1IM uogonJ }suoo sl '0N sa,L 6spuellamlo 14 001• u!y }!M uogonJlsuoo sl 1
uo!lonJlsuoo jo adAI . y
4,pay3e4e 111104 aoue!Idwoa i(6Jau3 )!oayosseW . aoue!ldwoa uo! }eAJesuoa A6Jeu3 . 6
yoea {o JagwnN sanolspooM JO saoeld84d 66u4eay to poylay I ;
6sauols ;o JegwnN 'a
suoisuaw!a . uo!lonJlsuoo Mau 40 a6e }ool aJenbs pasodoid •P
..payoelle a6eJe6 a aJay} sl . o
swoayles to JagwnN :pun Al!we; yoea u! SWOOJ ;o JagwnN q
-9410 IRwed oMi s(I!wed au0 : 6u1plmq 10 asa . e
:duiMOlioo ay; a ell wo3 •nulsnoy bul;slxe 0; uolilppe Jo pue esnoq MaN ;1 'Be
1aa4S - 110H Payoel4V sued
oN A saA luawaseq payslugun 6u!lenouad anReJJeN payoeuV
oN ^ saA woo.ipaq Mau 6u!ppV oN ^ saA woo.ipeq 6u!1s!xa ;o uo!leJ31IV
:jJOM
a Q 3 �'I 7 y p esodwd 40 uogduosaa 4 !J
[01 Ja440 [o] Bunn Ill sloaa [0] su6IS MaN uol ;llowaa E '6 tiossaaaV
0 siooa J
❑ § ❑ (s)uol;eJeuv sMopu!M ;uewaaeldaa 0 uol;lppV ❑ asnoH /am
(alge311a0e Ile 'I '13) )i210M 03S0d02id d0 NOIld1210S30 - 9 N011039
l
V I ;eu8!S aauA+oawog
•pamouud sM8T ie .]auao sgasngoesst jo awls pug sine') Wutuoz ieoo' pug a ;e ;s `saoueu!p.io uo;durequoK
;o J iD `apoJ 2ulpiing alg ;s aq; q ;!nn aouglidwoo io) ,u!i!q!suodsa.] saumsse pug sag►y►ao « .iaunnoauioq„ pau2!s .]spun a4J
• ;luuad s!q;.]apun noX io) 1 .]oM uuopad o; a.i!q noX
(s)uos .]ad .]o3 Nile!! aq As<u noA `pa ;e;ouud smug ie .]auaD sllasngogsseyq atop (q;go(' u! 3u!;insa .];ou saunfu! .io) saaiioidwg
o; s.]aiioidwg jo iii q !'i) £S I .]a;degj pug (uo! ;gsuaduioD ,s.1031.1oM) ZS i Ja;degD o; aoua api win. Imp pas!Apg aq osiy
. pans! s! ;luuad s!q; go!m s, Jo3 Ti.]onn aq ;3o uopaidwoo
uodn pug 8uunp 'amp o; awl; wo.q pannbaJ aq ii!nn aps qof aqi uo aouasaid moX aospuauns uopan.i ;suoD 2u! ;og sy
wawa Bu!Ppnq aq; .iapun pauuo;aaa *WM pits go .Jo; alglsuoasaa
aq Hogs aqs /aq ;up 'moiatp 8u!pl!ng ag; o; aige ;daoog two) u uo 'mom ;!u!pi!ng atp o; pwgns pugs „Jaunnoawoq„ gons
wuntoawoq a paJap!suoa aq ;ou pegs pouaa .183A-0M.) a a! awoq auo neg; a.JOW s ;ani ;suo3 oqA+ uosraa v •Sam ;onus
uuj 10 /pug asn gons o; tiossaoog sampans pagoulap .10 pagogue `; ulpannp ,Ci!ure3 onn) .]o auo a 'aq o; papua ;u! s! 10 `s!
alaq; go!gnn uo `ap!saa o; spua ;u! .10 sap!sai aqs /aq go!gnn uo pugi ;o pored a unno ognn (s) uos .]ad :Jaunnoawof ;O ao!;!a.1 i
'i'S'£'80i uouaaS uol;!pa gig!S `08L 2INDD •Jospuaans se
sue aauA O alp pup pap1AO.id `asuao!i a ssassod;ou saw own al! i Jo; ignp!A!pu! ug adg$ua o ;.]auMOawoq gons moire o; pug
sag!ure3 (Z)onn; 10 (1) mop s;3ulllaA+Q pa!anaao -Jaumo apniou! o; papua;xa SEM „s1ouMoawoq„ .►o3 uol ;dwaxa ;ammo aq j
uoilcIUIaxa .iauMp au><OH - •j1
❑ ON / � sa petpelly gnepply pa4g
;iwJed 6wpllnq ay! ;o aouenss! eq o leiuep ay; ul
;rise.] p!M iinep a sry; apinoJd o; einlre3 uogeoydde sigl q m paprwgns pue pa ;aldwoo aq;snw papule aoue.]nsul uogesuedwo0 sievoM
((9)092 § 'Z91 'o '"I'O'W) IIAVOIddV 30NVdf1SNI NOLLVSN3d1NO3 ,S213H21OM - 01 NOI133S
euoydaral
a;ep uogendx3 ssa.]ppy
) II of 3 3
.]agwnN uor ;e.];sr6a21 aweN Aueawo0
$ T S 1 4 Ir , 11 "v'I
9 eIgeoirddy :Jo ;ae4uo0;uewanwawl ewoH paia;slbO I
( c2. auoydeiej awnieu6is
6t), 13 t$5 29010 V 3) (>7i
a ;ea uogendx3 ssaJppy
Z r Gz1S d d 'VI \ • h o I
` " .]a asuao
t 1 L f O s r 1 I M" f 79 I (� :.]aploH esueoll to aweN
❑ algeogddy;oN I -t I :Jos!dueans uol;oru;suo0 pasue3n vg
S33IA213S NOI10f1211SNO3 - 8 NOI103S
:# auogd : uos iad ;3e11103
aag ;0 '9
aopadsui ;lulgwnid 's ao;aadsui luau ;aald •l' ;pap umoju C;!D •£ ;uaw;Judau 2 uiplmg 'Z g3luaH Jo pivot" 1
I
:(auo'IOala) kilaoq;nd 2umssi
# asuaai iwaad :tutu)" ao SID
imago unto; JO dua efq paja /dumod aq o; 'naJn s/gj u1 awn( jou oQ -diuo asn /nplffo
1 t 9, : # auogd
:ale a.inleUWIS
o < 1 j :
I I a L-- f` �--
73a1Joa pun anrj st anogv papinold uorjmulofui aq; jng; dinfrad fo sapjnuad pun suznd alp napu t/iaa £garaq op j
•U0U OIL.ian OREJ A0O aOULmsui a03 \JIG 3141 JO SUO fe2[;sOAUI
JO aogjO 01[1. o1 papaemioj aq /Cm luawams sujjo Moo a JET pasinpe ag •ao ;elo!n alp "sure ,Cep e 00.0SZ$ 01 dn jo
aug a pue 2Igu2I0 ?RIOM dO,LS E 3o UIJOJ 3111 111 sat;jeuad Irmo se gam se `;uauwosudwi .iea/C -auo aoipue 00 o; dn aug
e jo sai;Ipuad Irulwuo jo uotlisoduit ag; o; peal ueo ZSI •o jo ySZ uotloas .iapun pannbat se 32e1OAOO Omoas o; ainlie3
•(a ;ep uol ;eaidxa puu .iagwnu Sagod aq; 2ul,Nogs) aged uol ;eaelaap Sallod uol ;esuadwo3 ,samlaont aq; jo £do3 a gaegd
:d1Z/31e1S/CID :ssaippy a1!S qof
:a1eu uoi ;eaidxg :# oiZ •sut 3IaS .io # /Coilod
:mum Xuedwoj aoue.rnsul
•uopmuiofui
aj/s go(pun dagod aqj s/ nwo /ag •saalTo/thua !of aaunlnsu/ umjnsuadwoa ,srayiont Yuipinold si inq iado/duua un tun I
•iagwnu doiiod dwoo ,siavoM nagp apinoid psnw dagp `saa,Coiduia aneq slop iu uoo -qns agpn 'saa,Colduia
aneq saiupua asogp you JO iagpagm apeps pue siopoe.uuoo -qns aqp Jo auisu aql 2tumogs paags leuouuppe ue pagoeue psnw xoq sup rago pegr sioraeuuoD:
•gons Suueoipw unepa e Mau a uwgns isnw siopoe.nuoa apispno aim uagp pue 3poM i[e 2uiop aae dagp 8uueoipu! unepge sup uwgns oqm slaumoawoH
. uoueuuojui doilod uoipesuadwoa ,s.iaxioM nagp Ju1Mogs molaq uogoas aqp ino lig ow psnw 1# xoq sxoago imp iueaiidde dud„
[•pa.rinba.i aouemsui •dwoo
iag10 ❑ £ 1
,saa)I.roM ON] •saa,Coldwa ou aneg OM pine (�)i § ZS I • [•pannbai aoue.rnsui
�
s.iiedaa3ooil ❑'Z[ •dwoo ,saa)lpoM °N] jias,Cw
low .iad uot;dwaxa jo
suomppe Jo sireda.i 2utgwnid ❑' I I nag; pOSI0J3x0 aim" s.130!0 31.10M lie 2uiop .iauMoawog t? we I ❑ •£
suoipppe .io snedai "rowan ❑•ot s1t pue uoi ;e.iodaoO a an am ❑ •S [•pagnbal
1 aouransul duioo aOuemsui •dwoo ,s.ia)IaoM oN]
uol;tppe 2uipimg ❑ •6 •Altoedeo /Cue u! aw .kg &upl.iom
,s133I.10en aneq pine saaAoldwa
uog lowaU ❑ •g aneq s.io ;Oraluoo -qns °said, saa/Coldwa ou anal pie digs
2ullapowa21 •L wags pagoeni: ag; uo pa's!! - .iauurd JO .io ;al pdo id aios e ure I i 7
s.iopanuoo -qns ag1 pall!" aneq * •(awil -iEd Joipue linj) saa,Coldwa
not ;oru;suoO nnaN ❑ '9 Blinn is Coldwa a ure I ❑ i
I pie aoloanuoo Ieiaua2 a ure I ❑
:(pa gnbaa) pafo id jo ad�f i :xoq apeudoadde aq; 3laag3 zaa,foldwa ue noA aar
b J
7 0' S :# auogd o Q 14 3 a , q d7 :d!Ziarlspii3
4 r' J.S aM
-f‘05 :ssalppV
f "f e^ o f • I r i v f : (i snp►n►pu v uo g urtual oi ssau i sng) OUWEM
Algi�arl 3upd aseaid ) \( uoi3euiaoJuI Iueagddy
saagujnid/ suewp;aamsao ;ae.j ;uoD /s.japiing :3inepIJV aaueansul uoi ;esuadcuoa ,sjavoM
vjp /tos? ssvtu•M t H
11110 VW `uo ;soft 1 'rlr
uo / ?u l gsvdl 009
suoj ;vffr ;sanuj fo aa�fp
•
s ;uappavlv..gsnpulfo ;uajujvdaQ
w++
s ; /asnzpvssvyy fo 0 ; /va4xuou ujo,) aqj
„
/5
d(1$ M -r
1
Q
6
----1
C _
331 'd \14 o 7!)
-�- N
036
.-h <1 5o 0 d 0ZZ
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
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Fax # 617- 727 -7749
Revised 4 -24 -07 www.mass.gov /dia
513 .. -1 Pa") -42 S_J- 31-HaV) �`3N
'3 3 7d3 .
' 3 0 1. - z19QllS QcN
�al��n�1�5� BSI tnw
. 515 0 4 dr"cf S 1A1 WI )� 1J - 3
- 7 - 7vAA 9nc)A-ki
H -14 e
r 5
0
i ' U O.. , E 3v ° ' 03na; o › � va'0.N.S - O c n o 5 a i 0 .a of) 0 .E o
'ooa >a> °> a> � , ° „.•+ ° c �DA = . ° �� a U U$ zx .5, ,,-,s, a W ca UW a~
i�"y� !1•0...J ° mo c a n 0b� p o o /� � 5 . 3 00 o °• " 2c ° ' o A � .-•
> ;; - u 0, .74 o '7. .� o W . 5 o V a. l D z .z w " Cj a 4- Ca on w ,� 5 E •° t V c o
°gUoa . Qa °a, c' z ° ..5s..oao= a> cn❑ ° +, un 3 CD
I y O p O .+ O o O .� 1� a> O a, .0+ El ° p, cn o g = *FA' " E
S N0�,.0o0c ,., 0.0001 > O .0. v 4 4g 0 a im - ....� .G �
i o ... •� o '6, o•� o 2 a 0 a) . 6-. cw� 3 ° a ai on a,��q.. .a • ot>
pp ,2 U 'IA •-• .O c cl. • 1 U 3 1 o 4 ., ,., H a A . 0 ic{• a -- o '5 c
� �a>a a'3a a o. .,a,yy ... ..z -s-ca v, ° --" ° U
' �� oa w >�� oa> a`iw A � uw�a� (t $.. oA� > - -. CU U O w y 0
,., ooa v,,v`, 0 0� ° � =1Q '^ X p000CU -0 E.., x 0 a>
v .., s u CU v No 3 � Q a comm �c
u cn 3 o . . c "a .. o . ° 0. CZ v 0 b.O Z , '0 E o .� . ss
C/ 1 o • o ,, a c 5 o a x g . ' ° 3 .
�� ., - v oAOOda a>. 0. � �� cl+a i ° U� c a a a >o
o 0. ›,3 E� a> U a> o ` � v U y o t. a a3a F � vi -0 ,,, a >
a �w O p aa> m ^ O y ,... A o 3 ›,Egob4... oa> 3 °,
F. � U s>�� > a � o•• o ao a � i".c p `�'> �.
. •v 0 o ct => _0 o • Q o � o el.) v°, � '� o o x • '"" dy
s.� vi '•' a «i cd er ....4 ....4 F, a oA i ' . o o ... w ❑ o ❑ y c. . ° C U •,
o aU
c o ° n a p ,
(/) ao a> .,C p.dQa>cr�,aa i v�
3 2 . �� 1 a o a , o • a> cn o o � -, y
0 5 a , cn o v o o o ° o o •a•o s- c� a > o o v a c� ap c o U n o
r0 o , s o � ai ai O •
c. b.0 o >, U co 0 0 y 4- cn 0 .0 0 4'
O go oG N ,w 5 .° co c� O ,0, a) 3 c ) S. '� a •0 'O '0 E a 2 z•-.5 'O C 0 '
. b
a x o -O 4. a0 {�.� ° � '3ao " E a`�i¢�°0.ov��' 0 a 4 � r a'"i r °�c
I ) o p t a , 3 o o c> o ., v, Z U v> 0 ° a>w cl3"g.o >10 A c,i m
o 5C 3 n:0 E�,aaaiu U' a � O ^ ,„ .,.. a ao� ° �w :,'2 8 a)
E �o�.as7 .-1. 2 a o W, 0 00 .. a..).>c'' 02 E�0
0 ° - o o n c U � a 5 -0 'n a a s - ,�, � � sx� U xEn � • � a A > W
Q U W.AC �.. �c� y aU 0o A x. 0 0
o coy ° a> ..,'0 0 o a o o .,e.4 a a > Y � - a' c � ,.-4 `>' o 0 � b LI b� y. �
0 • E �„ 0 ° " t g � o ',-, 0 ` U ' CZ ,. ; -., ' C v' s Q cu s , ' S 5 • a a > a ' w a> w
`-, ° N a , csd - w 'o "d 0 o F-� 4- b N om _. E '' H 3 y ( a> cc, a, . O U •
. � y w .0 O
O s- cC a 0 �i o
-0 ' � O O a a z a 'o ,
a) a » s . O a> ca >,
0 -0 te ° o . r ? N N u N O 0
a. a wo ..o a, � - 3 0 0
a �a 6TS a> E a> 3 a, 3 U P
43 c4 0 c�:" O •.0 ° .9O SE',
F
0 3 .o ., C/) .n Q .. 'o w
U)
o
x 000, �• " x
..
Cn O .n3a>a co
o � a o
w a> € / z
W it? 'N, /, . '' t ‘ < '' c
cl U -, a • o
a
- Cd v Z v i 0 >_.
a 0 • = ° F 3 N LI
4. G •w wC o 0 o O .g
O a°> • .a .5., cad oA �' d r a a >, ▪ o >, cv s•.
ai . N .94 E',
I. G 3 • - in • , 4...,) . - . 0 ^ I A cd ° o.0 _ 0,5 a> .•�,, cC y 0 • '- i N 4 0
b a• cn a>
os U 04 U ° 0 � a>a :
° z 0' N 'd v > � 5v 0 U > a> x o p o 0
C CU a> --, .c s. ' ea C3 ni o ., v c� o c> 3 Gi
°> C °' ° • : 3 O r '" ,2; A cu o•o I „, ° o - •'--.n > ' 9 o 5 s- . a
cO E on^ -0 -2 cr3 U o
� o a> on. � � 'o , x �, a> a> , eso o n x oq ° ,. u o c • 0 a " " s a> . , CL ° 1 >
cd. o 0 ,6 -1 "' o s o... 0. 2• ° c R.:2 N o v a a
„,
a"i a' o v> I v f, . . 'v o o° o O ,� o m 8 E ,c x ' . c 1 a4 0
c O s. .a 3 vi >,w ,� a 'v (�� , a? >v 'iv' o • ' ..., y , ,a s- 'N a) a) �> a> a> p cn › . '� U
Ii V O = ,.5; O tso O - 5 N j1H Cf 0 0 4-, It, A ° a a CV v) U a> ti) ... - a N ° ai p .,-, a c� a ,i> O pp N v
, fix 4 4 'c ,p, v " c 0 acn ^ v C7 c� >' a) a> en ° a 3 a , o 0 - v v .a
z o v> s.0. 0 a) 3 0=, . a> b � ^ E 'w - = rn >ct a 0 a`>
'� G z O a> cQ w u v> - o .0 C 0 . 0 . ; ° O N cG 0 :' 2 O 'o A a 'v> a> w 0 , O • EL , 4., •a v b .6
=1,:-"a-we r , W 3 RS • ° 0 . ° •o ,.., E 0 -. AO E s.1 0 • ,0 0 .-, O >, U 'o O b O ° a a " ' 0
O . v b O2 N w O s., a O . A bA U.ab� 0 a s bA 4.. � ' • � V .... fi n . , a✓ a a) . 0 U ccd E .. N ° .� 0 >, u = E i "' [n '0 E a> c 5 d 0 • .. r -1 w aj w
ca , ....4 - „,• - � >� cu ua a aE
> >> x
b _
^' +, vvro� - a> z va' `= • v vc v >> -> 0 5r, .a s, o v o va , z.. o
oasc'co0of �,?aUaoGLd.oc .. ° °> > ,,„0 3 ..o° v> .. m
+
v i i o z on `d E ° ao v° `V o a ° - F- 3A E 0_0 v u 01° c , .a> ' o.
. '@ - ° >,'- a> o a.P oz A �1 ��VV x nb a i1 . , . o >, a>Ts ., Y U E c
O �� a o i � n 7. °a A� 1�• v v� v v d cv �°p° ° .ov� O ° m
r U., U . . ._•14--- ° , v' C +C F- u .". E N Z> o '5. 0 CI 05 a , ° p ° °
cu s
'*4 , F. x. -3a.o. an om °cOarw Loo � \ 0a - -44. 1 r �M 040�00 ,4 c°n�