An application was received from FAST SIGNS OF WOBURN representing Bom Dough, requesting permission for a projecting sign at the premises numbered 1 Canal Park. approval has been received from Inspectional Services, Department of Public Works, Community Development Department and proof of abutters mailing has been provided

@ City of Cambridge, MA 280281 Sign/Awning Permit Status: Active Submitted On: 7/12/2024 General Information Primary Location 1 Canal Pk Cambridge, MA 02141 Owner 1 CANAL OWNER LLC 2029 CENTURY PARK AVE SUITE 1370 LOS ANGELES, CA 90067 What option best describes this application?* Sign(s) Description of Proposed Work* September 4, 2024 Applicant ,l FASTSIGNS OF WOBURN J [phone removed] @ [email removed] * 155A NEW BOSTON ST WOBURN, MA 01801 Update of existing blade sign with 1/8" thick ACM panels being installed over existing sign Estimated Cost of Sign(s) in dollars* 650 Describe any existing signs or awnings that will remain (including the size of the remaining signs/awnings).* Existing blade sign 24x36"

Cambridge City Council approval may be required. Will one or more of the proposed signs extend six (6) inches into the public sidewalk?* Yes You must submit a Projected Sign Application and Abutter's Form to the City Clerk's Office. Sign Information Sign Text* Born Dough Coffee & Dough Type of Sign* Projecting Height of Sign (feet)* 2 Area of Sign (square feet)* 6 Height from the ground to bottom of the sign (feet)* 14 Illumination* Natural Width of Sign (feet)* 3 Height from the ground to the top of the sign (feet)* 16 Sign Material* 1/8" ACM

Weight of the sign (lbs)* 5 Width of Building Facade for Associated Use (feet)* 28 Contractor Contractor Name* DUANE D LEVY Address* 101 RANGER ROAD E-mail* [email removed] License Number* CS-063983 Contractor's Signature Signature of Licensed Contractor* Duane Levy Projection from the Building (inches) 39 Is the sign an accessory to a first floor store?* Yes Telephone* [phone removed] License Expiration Date* 10/06/2024 Date* 07/12/2024

Community Development Approval a Sign conforms to requirements of Article 7.000 a Sign requires a variance from the Board of Zoning Appeal a Comments a Exempt under Article 7.000 City Clerk Internal a Bond Number Attachments Drawing of Sign(s) Born Dough - Blade Sign Layout.pdf Uploaded by FASTSIGNS OF WOBURN on Jul 12, 2024 at 3:40 PM Contract with Sign Company Complete_with_Docusign_Bom_Dough_signs_-_ten (1).pdf Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:18 AM Proof of Insurance Workers Comp Affidavit 2024 - FASTSIGNS Woburn.pdf Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:27 AM REQUIRED REQUIRED REQUIRED

IF ' ·.-:a:: • Signed contract between property owner and applicant Complete_with_Docusign_Bom_Dough_signs_-_ten (l).pdf Uploaded by FASTSIGNS OF WOBURN on Jul 12, 2024 at 3:41 PM Blade Sign Install Cost.PNG ~ Blade Sign Install Cost.PNG Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:27 AM COI-GENERIC.pdf COI-GENERIC.pdf Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:28 AM UPDATED Born Dough - Blade Sign Layout.pdf Born Dough - Blade Sign Layout.pdf Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:28 AM FINAL LAYOUT- Born Dough - Blade Sign Layout.pdf Born Dough - Blade Sign Layout.pdf Uploaded by FASTSIGNS OF WOBURN on Jul 31, 2024 at 7:32 AM signed estimate client.jpg blade sign install 2024 born dough.jpg Uploaded by FASTSIGNS OF WOBURN on Aug 2, 2024 at 10:05 AM Born Dough - Sign Certification Form - signed dm.pdf Born Dough - Sign Certification Form - signed dm.pdf Uploaded by FASTSIGNS OF WOBURN on Aug 6, 2024 at 2:36 PM Cambridge Abutters.pdf Cambridge Abutters.pdf Uploaded by FASTSIGNS OF WOBURN on Aug 22, 2024 at 9:44 AM abutters application form.PNG abutters application form.PNG Uploaded by FASTSIGNS OF WOBURN on Aug 22, 2024 at 9:45 AM REQUIRED

History Date 8/15/2024, 6:26:31 AM 8/15/2024, 6:26:31 AM 8/6/2024, 2:39:49 PM 8/6/2024, 2:39:48 PM 8/2/2024, 7:50:12 AM 8/2/2024, 7:48:46 AM 7/29/2024, 7:29:00 AM 7/25/2024, 8:42:38 AM 7/25/2024, 8:37:57 AM 7/25/2024, 8:36:47 AM 7/12/2024, 3:41:19 PM 7/12/2024, 3:41:18 PM 7/12/2024, 3:41:17 PM 7/12/2024, 10:18:15 AM Activity approval step City Clerk Review was assigned to Lori Perez on Record 280281 Brian Mclane approved approval step Department of Public Works Review on Record 280281 approval step Department of Public Works Review was assigned to Brian Mclane on Record 280281 Daniel Messplay approved approval step Community Development Plan Review on Record 280281 Branden Vigneault altered approval step Review for Completeness, changed status from On Hold to Complete on Record 280281 Branden Vigneault changed Estimated Cost of Sign(s) in dollars from "350" to "650" on Record 280281 Branden Vigneault assigned approval step Building Inspector Review to Branden Vigneault on Record 280281 Branden Vigneault altered approval step Review for Completeness, changed status from Active to On Hold on Record 280281 Branden Vigneault changed Will one or more of the proposed signs extend six (6) inches into the public sidewalk? from "No" to "Yes" on Record 280281 Branden Vigneault altered multi-entry field Projection from the Building (inches), changed value from "" to "39" on Record 280281 approval step Community Development Plan Review was assigned to Daniel Messplay on Record 280281 approval step Review for Completeness was assigned to Branden Vigneault on Record 280281 FASTSIGNS OF WOBURN submitted Record 280281 FASTSIGNS OF WOBURN started a draft of Record 280281

Timeline Due Status Label Activated Completed Assignee Date ✓ Review for 7/12/2024, 8/2/2024, Branden Completed Completeness 3:41:18 PM 7:50:12AM Vigneault ✓ Community 7/12/2024, 8/6/2024, Daniel Completed Development 3:41:18 PM 2:39:48 PM Messplay Plan Review ✓ Department 8/6/2024, 8/15/2024, Brian Completed of Public Works 2:39:49 PM 6:26:31AM Mclane Review ✓ City Clerk 8/15/2024, Lori Perez Active Review 6:26:31AM ✓ City Council Inactive Approval ✓Bond Inactive FASTSIGNS 0 Sign Permit OF Inactive Fee WOBURN ✓ Building Branden Inactive Inspector Vigneault Review ~ Sign Permit Inactive

(JFFICE ()F 'fJ lE CI1-tY CLERK CA:\ 1HR ID(; E cnY I I.\ 1J., 795 i\l :\ S.S,·\G [l 1SE1~r s :\ \ 7::;_;",J C F. C.inl [HUDG l:., ~L'\~S:\CI 11:SE1 ·1 : ti.:! IJ9 1)1 ION~ (bl':') 3.J'>-4261.1 I '.\X (G 17) '4?--t2r,9 DIANE P. LHOLANC CITVCL.ERK !PAULA M. CRANE DEPUTY crn- CLERK cainbridg.:,, August 16th l'o the Hotmrubft. lhi= CiL.)' Council oflhc: C1Ly ofCrunbn:dge. IEACR PETITION MUST BI: ACC'OMPAf'\IED B\' A DR.AWING OF PROPOSED :SIGN, lND1CATIXG DF..SJGN ,\'.S'D DIM L"SIONS AND LOC i\ TION ON PREI\USES. The un.ck!rslgMdl re!.pec:tfully pravi: triat _B_o_n_n_D_o_u_g_h_. _ ________________ _ lNAME CJF BUSINESS} be gran tL-d ~lTiliL to 11...-red a sL_gn ofd11.! fol!owia~ spL"Cificisru.ms in front of premises located al 1 Canal Park Typ,: vf Sigl'l c.l!<Lr,g~1~ ~ 1T.o.nil19.-- 1,'S" illitl r.-..6 ls•11~ i,_dMhe~ r:l'IXlfii; or L1tl1,:n.\.i~ iltil!l t1ll11r:ri:ltl LL~ in ~'l•i\Sllu~iio 111 Rt?llding ffi31li!J to so O il Sisn. Bom Dough logo Si.2'1 24x36" W1:!igh1 _2_lb_s _ ____________ _ Pabllc Way l8" Obst~llon: A. · B. 13ft !Gn•c CXJX't disiam.-c sign 1s Lo cxCcnd ovc:r sidewalk.) (Also cx.'lct dlist.mce: fmm bottom or sLgn to sickwn.Lk) 3ft Tap. 15ft ,o fll - RE.t.l L\. TIO,, [-~ dl01' I J r/J/ Off> MY!ii;.,~ I C"l'lll" - f.rg,'ll!kl1~ 1•L1 ,1pt,1 .!il1..-.:L-.) S,-.r/il,i IJ i! 1l !'•M e ll,111'4lir111 ('1xh: - Pm~·11og Sign~] • A ~ jt!C:Li:ng si go !ills ll bi: coostrue:t.ed wboll~• of incombm;tibli!- mau!Iiak . • AIL si~s must mec-t mp.1irem1mts ofZonin~ Ordinances .md Building Code. • l"rlotr:; .s'«rwPI J 1.1 J.!W prorides iJ,, pan -~•e,,. ow11~, li'ho mai11tai1J'S a • • • strudlu·e in or i1N!T a strut ••• JhnO do so onfy QII the condition that D1el1 maintt!l11111tt sl1nll fn comidaed as nn agrt~111ttnl on Iris part m kcrp //,e .mme and tilt mn•n tnut!.o/ i 11 good npnir 11nd e011dilio11, aJ all tima dr1ri11g hi5 011rnermip.. and to il1dt!m11if.F mrd s11n-e htrn11/;:ss tlu: CitJ• ngaimt 1111J1 and all dllNlflJ:6, ctl'St or upttrua fllhiclr ii may slfilai14 or be requind to pay by rmMJIJ of .s.vd1 • •• ~1rucl11u·. '" l1ROl'tltl"\' 0\\'1' tll OR Al 11 ltORl.l.£1> At:.l!'.:,"•ff ll~ lll:BY ST.U~ 't 11,\1 IN.'ORi,U l'ION IS 'l'RLI£ 1:011U:. bL\io1 tW IJ1.SiUle:K .._,.....OWi .F.OGt: AJ\l}, l ').'Df.RST ANTH~G tJNPf.R l',\ N S A ND ff:N .\l.nr Or Pf'.R,ll 1( '\". 1 Canal Park Cambridge MA I' ---- - - ~-------------------- --------------- ( P'iri1p~FI)' vw,,,.-, " 1 o,y,,111,i/i:-u 11g!.!11.0 (A!.11.h~ ,1 (T1d Nt•) , ;:.. .• .,..._ .. /1~.ucf.l {Jm,.,. 1 Canal Park Cambridge MA 1 --------------------------------=-------- ------ (A1hir1~ ... ,. . .,,., , ! Adclr~ ) tTel N'o ) Reset Print

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CI1Y OF CAMBRIDGE Community Development Department City Hall Annex, 344 Broadway, Cambridge, MA 02139 SIGN CERTIFICATION APPLICATION Please fill out this application to indicate the number, type, and dimensions of signage for your building. If you are unsure of the type of sign and/or allowable dimensions, please review the following pages of this application and Article 7.000 of the Zoning Ordinance. Please note the following additional requirements: • All signs must receive a permit from the lnspectional Services Department (ISD) before installation. Community Development Department certification action does NOT constitute issuance of a permit or certification that all other code requirements have been met. Do not contract for the fabrication of a sign until all permits have been issued, including City Council approval if necessary, for signs in the public way. • Any sign or portion of a sign extending more than six (6) inches into the public way/sidewalk must receive approval from the Cambridge City Council and a bond must be posted with the City Clerk. For questions or additional information, please contact cddzoning@cambridgema.gov. APPLICANT INFORMATION Applicant Name: FASTSIGNS Woburn/ Vasu Patel Phone: [phone removed] Email: [email removed] Sign Address: 1 Canal Park, Suite 110, Cambridge, MA 02141 CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

PROPOSED SIGN Please fill out the information below and attach a sketch of the proposed sign to the application. Each proposed sign requires an individual form to be filled out. For further information on sign types, see the below page. Sign text: Born Dough Sign type: Reface of existing blade sign with 1/ 8" thick ACM panels Area in square feet: 9sqft. Dimensions: 2ft H X Placement height in feet: 16ft from bottom of sign Depth from fa9ade: 3ft wide blade sign Illumination: None Sign frontage in feet: Storefront: 26ft W 3ft L Area of existing signs to remain: existing blade sign to remain 2x3ft COMMUNITY DEVELOPMENT DEPARTMENT CERTIFICATION FOR INTERNAL USE ONLY Sign conforms to requirements of Article 7.000: YES Sign requires a variance from the Board of Zoning Appeals: NO Comments: Proposed non-illuminated blade sign meets the dimensional and illumination requirements of Article 7. Signature: COD Representative Date 8-6-24 C ITV OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

OVERVIEW BY SIGN TYPE Please note that this guide is intended to provide an overview of requirements by sign type. Sign shall mean and include any permanent or temporary structure, device, letter, words, model, banner, pennant, insignia, trade flag, or representation used as, or which is in the nature of, an advertisement, announcement, or direction and which is designed to be seen from the outside of a building. For further information on specific requirements, consult Article 7.000 of the Zoning Ordinance. PROJECTING SIGN A projecting sign is attached to and projects from a building face, including marquee, canopy, and awning mounted signs. I I _, II ,1~1111) / I I,, ,- 1 J , r ,.,....,,.."I MAX13 ft: .- 1 1 ' SQFT IFPROJE v· . - I ' I EXCEEO '!1<lN . 1r 1 ,J= 1~: 1 :'=~ I ,i't NAlURALANDCT"' .. ~J, ~ --- I 1~·1 r-; 1~:i)N 1' '1 .,, -.J.. ONLY I I '• . ' I I \ · i. _ ! - ~ \ .Q., I .• --.l-1 U ',\ 7 ·.'.ii~ _,.,_._ 1 - I ' ,---1 - L~~_J ~tP,§.'--L_- .... ESTABLISHMENT .... . .... .... \ .... ') - - SIGN FROITTAGE ~A'!';.~ElOF BUILOl~G TO STREET WALL SIGN A wall sign is affixed so its exposed face and all sign area is parallel to the plane of the building. I•.=-,-_-- 1~~·-- - _ __,J,='j~ - ~ ,Y __ (Jj r(.~ · 4=-- _k - ~ \\3-f \ lcf FROITTA • - - l "-.1< - - LENGTHOFBUll:DING di "(} - - - -PARALLa-TO,STRrn-.\ FREESTANDING SIGN A free standing sign is attached to or part of a self-supporting structure and is not attached to any other structure. ' I 11\ le , ;,,_, I \.•I"""•~_,.-- J '1/IY/ L.\ii r ti j•11 1"· . ~,1' )JuiJG~I..., ·\l I , 'l I I r-1 / ll1 I I \ . _- .J l. . I•, " - ' • '/ I • ..J I J,I. •1d);l ~. \~ ( _•, .,,A /, ,..,...1 I! " I .- .::-· ~$i1J1 l11111?. r·1 17 1 ' f,_ -.:-.:71• "\.J J?.,,,1 I 1 1 ' '17 ,.,./>-;,,.,:;:;, I ,.~ ... ~•.JIJL, ,; I ,,;;~-- •1 1,- f L"I '.::c)1}'l®. /~J!/JDJU (, I /~ SQFT l // -I r·-11·7 ~7 l fl.-,f1 r7 rJ,J::-,,_ 14i '11' ~-1~\ IT\qn~ I 'l \ ~ r :;+i:J , . ''.,u-L I I I I j 1FREEi l~'- : -- NATURM. I _ • ,I M~ .. ! STAN I !...-AND ElITTRNAL I I -' L-•• " 1 lS 1 1 --J ' ILLUMINATION - 7 ABOVE l DING fr ) \ _..- __ ... . GROUND I SIGN I .••• -- ------- . -----;,:--. \ ::-.1.-::, __ ~- ~RNAL 1',LUMINATION __..,~ I , • • -· • ."' ' -;,-.::'. - 1 WITH CONDmONS • - ,.· 'L ---- / ~ 2SIGNSPElH.0T ---- / ---- ,,,.,. --- ,,,.// _,,,,,.· ......... J - -. 1-· -- ILJ ·1 - .I / __..,/' CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

3 I !Exterior Sign • Blade Sign 2 $175.00 S:350.00 $350.00 08/02/2024 (::(:net:Jted On: 7/3 J~024 7'.2.5 !iM Pag0 i 1:.if aa. 3.1 DHJandlMax-Metal 3mm 1/.8" - Pan Qty: 1 Width: 36 . 00" Height: 24.00" Sides:·1 Notes: 1 /8"' th lck A.CM lN p r1 nt@d graphks (1ty 2 each .4 tnsta lllation 1 $300.00 .'$0,00 $-300.00 4.1 ~nstal lationi a Text: ~ qty 2 o ur.sid@· blad@ sign tncludtng wrapping th@ si d@s whit@

3 · I Exterior S1191 - Blade Stgn 2 $175.00 $350.00 $350.oo] Genu:Jr~~d On: 7/3V20211 7:25 AM Pdge l iJt' 2 3.1 Di B-ond/MaxsMetal 3mm 1/e-' • Pa,rt Qty: 1 Width,: 36.00" Height: 24.00" Sides: 1 Notes: 1 /8" th id:: ACM UY pnrnt@d graphics qty2 @ach 4 l1nsta lladan 1 $300.CIIOI S0.00 $:300.00 4.1 lnstal lation ., Text: • qty 2 o u!isld@ blad@ ~n lndudl ng wrapping. th@ stdes ,.w,fm

Client: Born Dough Project Location: Canal Park, Cambridge, MA FA5TSIGNS. Make Your Statement'· Woburn, MA Scan QR Code to visit our website [email removed] 155A New Boston Street Woburn, MA 01801 [phone removed] Salesperson: Vasu Prior to signing off please make sure all spelling/sizing is corrrect. Production will not begin without a signed approval on the final layout. All artwork designed/created is Copyright @2024 FASTSIGNS of Woburn. Na part of this artwork shall be duplicated, altered, exhibited in any manner or used for any purpose without written permission of FASTSIGNS of Woburn. All locations are individually owned and operated.

BLADE SIGN: OVERVIEW EXISTING MOCKUP New panels to be installed over existing faces no changes to the sign structurally ., . ~ • FA5fS/GNS Final Approval Signature: Date: Make Your Statement Woburn, MA

BLADE SIGN: MEASUREMENTS: 36.0in 32.lin bOmdough coffee & dough 16.6in SIGN DESCRIPTION: ,- .~ II) in -+- T C") ..t)i_ 1/8" thick ACM uv printed graphics with bottom and sides to wrapped in white matte cast vinyl. qty 2 each 0.63SQFT .~ 0 ""' N SIDE VIEW: ,I -, ~ EXISTING SUPPORT ~ ACM BLADE SIGN , • 1 BUILDING WALL COLOR: ~ Digitally printed D White . ~~~ Final Approval Signature: Date: f'-1.Jkc Your Statement Wob11rn, MA

Client: Born Dough Project Location: Canal Park, Cambridge, MA FA5TSIGNS. Make Your Statement'" Woburn, MA Scan QR Code to visit our website [email removed] 155A New Boston Street Woburn, MA 01801 [phone removed] Salesperson: Vasu Prior to signing off please make sure all spelling/sizing is corrrect. Production will not begin without a signed approval on the final layout. All artwork designed/created is Copyright @2024 FASTSIGNS of Woburn. No part of this artwork shall be duplicated, altered, exhibited in any manner or used for any purpose without written permission of FASTSIGNS of Woburn. All locations are individually owned and operated.

BLADE SIGN: OVERVIEW EXISTING MOCKUP New panels to be installed over existing faces no changes to the sign structurally • FA5TS/GNS Final Approval Signature: Date.· Make Your Statement Woburn. MA

BLADE SIGN: MEASUREMENTS: 36.0 in 32.1 in bOmdough coffee & dough l6.6 in SIGN DESCRIPTION: ,- .£ l/) LI) -J..- r (") #- 1/8" thick ACM uv printed graphics with bottom and sides to wrapped in white matte cast vinyl. qty 2 each 0.63SQFT .£ 0 'SI' N SIDE VIEW: J_ -, ~ EXISTING SUPPORT >-I-- ACM BLADE SIGN , • 1 BUILDING WALL COLOR: ~ Digitally printed D White • ~~~~s Final Approval Signature.· Date· Make Your St,ltemcnt Woburn, MA

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Client: Born Dough Project Location: Canal Park, Cambridge, MA FA5T5/GNS. Make Your Statement·· Woburn, MA Scan QR Code to visit our website [!l fl [!l~ [email removed] 155A New Boston Street Woburn, MA 01801 [phone removed] Salesperson: Vasu Prior to signing off please make sure all spelling/sizing is corrrect. Production will not begin without a signed approval on the final layout. All artwork designed/created is Copyright @2024 FASTSIGNS of Woburn. No part of this artwork shall be duplicated. altered, exhibited in any manner or used for any purpose without written permission of FASTSIGNS of Woburn. All locations are individually owned and operated.

BLADE SIGN: OVERVIEW EXISTING MOCKUP ~ - ' . - New panels to be installed over existing faces no changes to the sign structurally • FA5TSIGNS Final Approval Signature: Date: Make Your Statement Woburn. MA

BLADE SIGN: MEASUREMENTS: 36.0in 32.1 in biimdough coffee & dough 16.6in SIGN DESCRIPTION: --r- ,£;; in l/) -+- T C") ~ 1/8' thick ACM uv printed graphics with bottom and sides to wrapped in white matte cost vinyl. qty 2 each 0.63SQFT ,£;; 0 'Sf' N SIDE VIEW: J -, Cil----1--- EXISTING SUPPORT ~ ACM BLADE SIGN · I 'I BUILDING WALL COLOR: ~ Digitally printed D White . ~~~ Final Approval Signature: Date: Milke Yo{/, Stdtemenc Woburn. MA

DocuSign Envelope ID: 9888C415-905F-48FD-9825-2572C3797FEB CONTRACTORS AGREEMENT FORM I Susie Harborth, ( on behalf of 1 Canal Owner, L.L.C.) (landlord) authorize and give permission to FASTSIGNS of Woburn to fabricate & install signage at 1 Canal Park, Cambridge, MA 02141 (on behalf of Born Dough) (address). Landlord Signature____._[ ~_:_::_~:::~=-~ 68_,,,.- __ _____ _ Date 7/812024 ~ DocuSlgned by: Ten ant Signature --L=l\wci,,.,.,.. 3CD"""'BA!=.s~=2A ....... sa ... '-·I\\ ----- Date 7/8/2024 ------ Contractor's Signature __ ½_tZ<U? _ A_~ ______ _ Date 7(n ... /JL, ) C FA5TSIGNS. Make Your Statement'· 1 SSA New Boston Street Woburn, MA 01801 [email removed] [phone removed]

DocuSign Envelope ID: 9B88C415-905F-48FD-9825-2572C3797FEB CONTRACTORS AGREEMENT FORM I Susie Harborth, ( on behalf of 1 Canal Owner, L.L.C.) (landlord) authorize and give permission to FASTSIGNS of Woburn to fabricate & install signage at 1 Canal Park, Cambridge, MA 02141 (on behalf of Born Dough) (address). Land lord Signature ___ [_+_:::~:::~~=-:s,e:,,-s ... ------- Date 7/812024 r-:;-DocuSlgned by: Tenant Signature ---=L~="'"J C,,,,,, O0A=!s=~=·,0,--_ __ il\\ _____ _ Date 7/8/2024 ------ Contractor's Signature __ Yt._a<tU_A_~ ______ _ FA5TSIGNS. /vlake Your Statement'· 155A New Boston Street Woburn, MA 01801 [email removed] [phone removed]

The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:_B_u_s_i_n_es_s_S_i_g_n_s,_L_L_C_. _________________ _ Address: 1 SSA New Boston Street City/State/Zip: Woburn, MA. 01801 Phone #: [phone removed] ,---___:::~ _ ___:_--=:==::::::::::================---, Are you an employer? Check the appropriate box: 1. [xi I am a employer with 4 employees (full and/ or part-time).* 2. D I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. D We are a corporation and its officers have exercised their right of exemption per c. 152, § 1 ( 4 ), and we have no employees. [No workers' comp. insurance required]* 4. D We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance reg.] Business Type (required): 5. □Retail 6. D Restaurant/Bar/Eating Establishment 7. D Office and/or Sales (incl. real estate, auto, etc.) 8. D Non-profit 9. D Entertainment 10.0 Manufacturing l I.0 Health Care 12.[XI Other Printing of Vinyl Graphic Signs & Installation *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. ••!fthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Hartford Insurance Co. of the Midwest Insurer's Address: One Park Place, 300 S. State Street, 7th Floor City/State/Zip: Syracuse, NY 1 3202 Policy # or Self-ins. Lie. # 76 WEG AC1921 Expiration Date: 01-01-202S 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 for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: SeaH s~ Date: 01-01 -2024 Phone #: [phone removed] Official use only. Do not write in this area, to be completed by city or town official City or Town: _______________ Permit/License # ______________ _ 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.mass.gov/dia