26-005 V VHV
W RKERS COMPENSATION
0
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S60UB-0746N82-0-14)
RENEWAL OF (6S60UB-0746N82-0-13)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 10456
1.
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INS AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST
1592 BUG HILL RD PO BOX 375
ASHFIELD MA 01330 SHELBURNE FALLS MA 01370
Insured is A PARTNERSHIP
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-20-14 to 05-20-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
m—
a� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
a�
AM0
w—
D. This policy Includes these endorsements and schedules:
op SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
oS
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-02-14 LP ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MIRICK INS AGENCY 73LGB
004948
' The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office tce of Invest1gations
w
r
I Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorOndividual): Shirley A. & Gregory A. Lilly, d/b/a Hilltown Tents
Address: 1144 Watson Spruce Comer Road
City/State/Zip: Ashfield, MA 01330 Phone#: (413)628-4577
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with 3 4. F1 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
ship and have no employees These sub-contractors have g. F-1 Demolition
working or me in an capacity. employees and have workers'
g Y P h'• 9. E] Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. r-1 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152,§1(4),and we have no Tent Rental
employees. [No workers' 13.MM Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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: Hartford Underwriters Insurance Company/Mirick Insurance Agency
Policy#or Self-ins. Lic. #: 6MUB-07461SI82-041� Expiration Date: 0512011
Job Site Address: ��7 �/�� '���� City/State/Zip: � o%
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 imprisonmient, 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 t ins and penal ksofpedury that the information provided above is true and correct.
Signature l� Date:
Phone#: (413) 628-4577
Official use only. Do not write in this area,to be completed by city or town offilcial.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
' IMPORTANT DOCUMENT
Certificate of Efame &sistance
ISSUED BY Date of Shipment
8/28/2014
Cl�IQR
Registration Number �
F-140.01 INDUSTRIES INC. Sales Order#
SO-609415
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described are inherently flame retardant and were supplied to:
72961
HILLTOWN TENTS
1592 BUG HILL RD
ASHFIELD MA 01330
USA
5 T
N �
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, ULC 109.
Serial# 8108985(2)
Description of item certified: CENTURY MATE EXPANDABLE END 40WX20 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MANUFACTURING INC PHILADELPHIA PA
Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC
lulujiZuEe 11:1:e 141-J5tJ[1ZL1 N I UN bLJJ VtV I YIAUt Mel 02
Litt 40 0
of Noxthampton
Massachusetts
LWARTMMM OF BUTr.Drm xvsvz=X0Wy
212 main stxeet • Iftpicipal BU:Ljdirkv
APR F�L
2 3 TENT PERMIT APPLICATION
Electric,Plumbing&Gas,Inspections (For Tents over 120 square feet)
Northampton.MLLLO60 � Permit Fee: $26.00 Check#
PLEASE TYPE OR PRINT ALI.INFORMATION
I Name of Applicant
OtA4
Address: Telephone- �5
_Tele
2. Owner of Property: /c
S, -2, ke- 2,
Addres f 61 aa Telephone:
3. Status of Applicant_Chvner _X_Conftdor
A. Tent Location Address): I L/
4"" KK
/-V— rA,4 6/Le-)G 0
P7
M7.
5. Use of Property: Residential: Commerdal:
S. bascription of Tent:
Size:_ vox
Occupant Capacity.--_
Dates of Use:
7. ALL RVAILORMSST BE COMELF-TED:PERMIT CAN BE QENIED DUE 3M
B. Certification:I hereby certify that the infounation contained herein is true and accurate to the beat
of my knowie0ge.
DATE: APPLICANT'S SIGNATURE
NOTE,ISSuence of a pamit does not relieve an 2AAaant's burden to cam*with vA zonkg requeemejft
and d*6n al required PWMft from the CWmervallon C40IMbOM Dapwbmt of Pulft Wodw ww aw
applemble,permit WwthV a*wrmm_
OLD FERRY RD BP-2015-1071
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 26-005 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Tents BUILDING PERMIT
Permit# BP-2015-1071
Project# JS-2015-002023
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq. ft.): 33541.20 Owner: WILLARD HAROLD F&DORIS A TRUSTEES
Zoning: Applicant. HILLTOWN TENTS
AT: OLD FERRY RD
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628-4577 WC
ASHFIELDMA01330 ISSUED ON.51512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 40 X 40 TENT 5/22- 5/26
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Date Paid: Amount:
Building 5/5/2015 0:00:00 $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner