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D&PARTMENT OF BPSLDLNG 1P+TF.CTLORS
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TENT PERMIT APPLICATION 2019.
(For Tents over 120 square feet) ��i�oAT�'gMv on�MAo+oe�a
Permit Fee: Se5�11)B Check#
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of ApWicant H!(l'l�D/,O'n �en>�
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3. StatuectApplicant_W.mr ,s—Coorrader /10/"63
4. Tem location Addreeel: L—�Sf'P��rld Kc/
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5. Useof Pmpedy RSI•X/ oommen9at_
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occupantcMadty 6-1
Dates of UM
r. ALL INFORMATION IdUST RF COMPLETED PERMR CAN BE OENIEO OL TO i_4CK OF INFORMATION
8. Certification:I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: 6/"'? APPLICANT'S SIGNATURE
NOTE:Issuance off p orrR does not relieve an applicant's burden to cm*wfth all zoning roqutancrds
and obtain all required Pward from the Conservation Commission, Departrnent of Public Works end other
aWlIcabie pemdt granting aulhonnes._
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manufachned
_ ISSUED BY Manufactured by 5/2013
Snyder Manufacturing,lue Fred's Tents&Canopies
3001 Progress Street 7 Tent Lane
Dover,OR 44622
Stillwater,NY 12170
This is to certify that the materials described below have been flame-retardant treated
(or are inherently nonflammable)
FOR Hilltown Tents
1592 Bug Hill Road
Ashfield MA 01330
Certification is hereby made that.(Check"a"or"b")
a)The articles descnbedbelow this Certificate havebew treated with a flame-retardant chemical approved and
registered by the Stam Fire Marshal and that the application of said chemical was done in conformance withthe
laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Name of chemical used Chem.Reg.No.
Method of application
X I (b)no articles described below are made from a flame-resisum fabric or material registered and approved by
j the State Fire Marshal for such use.
a NFPA-701 (large scale)
Trade name of flame-resisraut fabric or material used Blackout White
Reg.No. 140.01
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Plant Supervisor
Product Description 20x40 Center Peak Customer Invoice# 27728
The Commonwealth efMassachusetts
Department of IndustrialAccidents
1 Congress2Suite 100
Bacton,MAA 00211 14-20177
w ..mare&g"Idhr
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADDlieant Informadon Please Print LeeiblY
Business/Organization Name: Shirley A Lilly&Gregory A Lily,Partners dba Hilltown Tents
Address: 1144 Watson Spuoe Comer Road
City/State/Zip: Ash8ekl,MA 01330 Phone#: (413)626-4577
Are you an employer?Check the appropriate box: Bushes Type(required):
1.❑✓ I am a employ.with 4 employees(fall and/ 5. ❑Retail
or part-time).' 6. ❑Restaurent/Bar/Eating Establishment
2.0 1 am a sole proprietor or partnership and have no 7 ❑Office and/or Sales(incl.seal estate,auto,etc.)
employees working for me in any capacity.
[No workers comp.insurance required] 8. ❑Non-profit
3.❑ We ere a corporation and its of otts have exercised 9. ❑ Entertainment
their right of exemption per c. 152,¢1(4),and we have 10.0 Manufacturing
no mployees.[No workers comp.insurance required]' IL[]Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees.[No workers' comp.insurance req.] 12.❑Other
-Any M'stiesm that ehaeka boa#1 muat.leofilloat ft uctioo below showing their w s,s'compvuation pallyinfo,nution.
^Ifthe mspmte oficm have exempted themselves,but the cospataion has otheremployces,awolaus mmprnsatiou colic,is twlvimd and such an
osganiutioo aboald click box#1.
I am an employer that is providing workers'compensation insurance for my employees Below h the policy infrmation.
insurance Company Name: Hartford Underwriters Insurance Co MIriek Insurance Agency
Instner's Address: 26 Bridge Street
City/Smm/Zip: Shelburne Falb,MA 01370
Policy#or Self-ins.Lit.# 6S6OUB-7H79236-A-19 Expiration Duo: 02/15120
Attach a copy of the worker:'eompematiun policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required coder 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 toren of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
7 da hereby nrtify,under pains and pens fperjury that the injormunan provided shove u nue and rorrerr.
S611114
Phone#: (413)628-4577
01clol we only. Do mar write in this area,In be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health L Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
uses W6.
V uM%-#
WORKERS COMPENSATION
AND
3/f EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-7H79236-A-19)
RENEWAL OF (6S60UB-7H79236-A-18)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1 NCCI CO CODE: 10456
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INSURANCE AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST.
1592 BUG HILL RD SHELBURNE FALLS MA 01370
ASHFIELD MA 01330
Insured is A PARTNERSHIP
Other work places and identification numbers are shown In the schedule($) attached.
2. The policy period Is from 02-15-19 to 02-15-20 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 at the state(s) listed here:
MA
m= B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
Rem 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
o 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 06B
u=
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - E%TENSION OF INFO PAGE
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: 01 -1 B-19 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MIRICK INSURANCE AGENCY 73LGB
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