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TENT PERMIT APPLICATION
(For Terft over 120 square feet)
Permit Fee: $29.00 Check q-4aid
PLEASE TYPE OR PRWT ALL INFORMATION
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Dates of use: 9l a-//8
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S. Cerditwdm:I hereby eartW dust the iMptmdbn contained herein Is true and accurate to the beat
of my knowledge.
DATE /S// APPLJCANT'S SHiNATIIRE c' /
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,AIA 021142017
IF www.massgov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Bush ess/Organization Name: Shipley A.Lilly S Gregory A. Lilly, Partners dba Hilltown Tents
Address: 1144 Watson Spruce Comer Road
City/State/Zip: Ashfield, MA 01330 Phone q: (413)628-4577
Are you an employer?Check the appropriate box: Business Type(required):
1.0 1 am a employer with 3 employees(full and/ 5. ❑Remit
orpart-time).* 6. ❑Restaumnt/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7 ❑Office and/or Sales(met.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance requhedj` I1.❑Health Care
4.❑ We are a non-profit organization,staffed by votunteers,
with no employees. [No workers'comp.insurance req.] I 12.0 Other Tent Rentals
'Any applicant that checksboa#1 must also fill wt the section blow showing aa:irworkers compensation policy infomation.
"If the contains,officers have eacmpred@emulvas,but the cerpnniva has oaierenpbym,a warkers conpeavadon polity is raquirN and such an
or8aninticn should checkbox#1.
I am an employer that is providing workers'compensation insurance far my employees. Below is the ptdicy information.
Insurance Company Name: Hartford Underwriters Insurance Co.,!Mirick Insurance Agency
Insurer's Address: 28 Bridge Street
City/State/Zip: Shelburne Falls, MA 01370
Poficy#or Self-ins.Lic.# 6S60US-7H79236-A-18 ExpirationDate: 2/15/19
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 fm insurance coverage verification.
I do hereby certify,under al ' s and pemahi rjury that the information provided above is hue and correct
Signature, --r"/ - -'/ Date. /���
/
Phone#: (413)628-4577
Official use only. Do not write in this area,to be completed by city or town ojficiat
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.msaz.8ov/d'n
VUAU
f WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 011 A)
POLICY NUMBER: (GS60UB-71179236-A-18)
RENEWAL OF (6S601.18-71479236-A-17)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 10456
1.
INSURED: _ PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INSURANCE AGENCY
GREGORY DBA HILLTOWN TEM 28 BRIDGE ST.
1592 BUG HILL RD SHELBURNE FALLS MA 01370
ASHFIELD MA 01330
Insured is A PARTNERSHIP
Other work places and Identification numbers are shown in the schedule(s) attached.
2. The policy period is from 02-15-18 to 02-15-19 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 stats(s) listed here:
ac MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
az item 3A. 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: 3 1000000 Each Employee
s C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 066
.a�
m�
D. This policy includes these endorsements and schedules:
o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
oz
4. The premium for this policy will be determined by our Manuals of Rules, ClasaMlcations, Rates and Rating
Plans. All required Information is subject to verffication and change by audit to be made ANNUALLY.
DATE OFISSUE: 01-18-18 WC ST ASSIGN: MA
OFFICE: ORLANDO- DA HTFD 05G
PRODUCER: MIRICK INSURANCE AGENCY 73LGB
M404
IMPORTANT DOCUMENT
Cern,fuate of iFlame ftmstance
ISSUED BY Date of Shipment
C7/282016
Registration Number �I�USnow' Sales Order#
F-140.01 S
INC4386
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
. ..CACI
M
'�.y FIRE M�p
f REKp
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# 8108901 (1)
Description of item certified: CENTURY MATE 3011V X 30 SNYDER WHITE VINYL 16OZ
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MANUFACTURING INC-DOVER OR
Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC