An application was received from Ricky Zeng representing Love Art Sushi, requesting permission for one (1) projecting blade signs at the premises numbered 1 Canal Park. approval has been received from Inspectional Services, Department of Public Works, Community Development Department and abutters.

January 22, 2026 City of Cambridge, MA Applicant Primary Location Record No: 1 Canal Pk 1192945 & Ricky Zeng Cambridge, MA 02141 2 [phone removed] Sign/Awning Permit @ [email removed] Owner Status: Active A 259 Quincy Ave. 1 CANAL OWNER LLC Quincy, MA 02169 Submitted On: 12/11/2025 10100 SANTA MONICA BLVD 15TH FLOOR LOS ANGELES, CA 90067 General Information What option best describes this application?* Sign(s) Description of Proposed Work* install a blade sign mounted on the existing bracket to the wall. Estimated Cost of Sign(s) in dollars * 2200 Describe any existing signs or awnings that will remain (including the size of the remaining signs/awnings).*

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* Love Art Sushi Illumination* Type of Sign* External Projecting Height of Sign (feet)* Width of Sign (feet)* 3.5 2.75 Area of Sign (square feet)* Height from the ground to the top of the sign (feet)* 9.62 14 Height from the ground to bottom of the sign (feet)* Sign Material* 10.5 Aluminum, LED, Acrylic, vinyl

Projection from the Building (inches) Weight of the sign (Ibs)* 34 30 Is the sign an accessory to a first floor store?* Width of Building Facade for Associated Use (feet)* Yes 42.5 Contractor Contractor Name* RICKY Z ZENG Address* 50 Duncan Cir E-mail* Telephone* [phone removed] [email removed] License Expiration Date* License Number* CS-113216 07/13/2026 Contractor's Signature Date* Signature of Licensed Contractor* 12/11/2025 Ricky Zeng

Community Development Approval • Sign conforms to requirements of Article 7.000 ® Sign requires a variance from the Board of Zoning Appeal - - * Comments I Exempt under Article 7.000 - City Clerk Internal & Bond Number Attachments REQUIRED Drawing of Sign(s) Love Art Cambridge.pdf Uploaded by Ricky Zeng on Dec 11, 2025 at 9:08 AM REQUIRED Contract with Sign Company Invoice.pdf Uploaded by Ricky Zeng on Dec 11, 2025 at 9:18 AM Proof of Insurance REQUIRED Workers Compensation Insurance Affidavit.pdf Uploaded by Ricky Zeng on Dec 11, 2025 at 9:11 AM

REQUIRED Signed contract between property owner and applicant Landiord Authorization (2).pdf Uploaded by Ricky Zeng on Dec 11, 2025 at 9:08 AM Sign_Certification_Form_template_Tue_Jun_10_2025_09-29-31.pdf Sign_Certification_Form_template_Tue_Jun_10_2025_09-29-31.pdf Uploaded by Ricky Zeng on Dec 11, 2025 at 9:19 AM Sign_Certification updated.pdf Sign_Certification updated.pdf Uploaded by Ricky Zeng on Dec 12, 2025 at 3:19 PM 1 Canal Pk_Approved Sign Certificate_20251216.pdf 1 Park St_Approved Sign Certificate_20251216.pdf Uploaded by Idelcia ReBeca Mapure on Dec 16, 2025 at 1:31 PM AbuttersApproval.pdf AbuttersApproval.pdf Uploaded by Jessica Chiep on Jan 8, 2026 at 1:19 PM Record Activity 12/10/2025 at 3:31 pm Ricky Zeng started a draft Record 12/11/2025 at 9:08 am Ricky Zeng added file Love Art Cambridge.pof 12/11/2025 at 9:08 am Ricky Zeng added file Landiord Authorization (2).pdf 12/11/2025 at 9:11 am Ricky Zeng added file Workers Compensation Insurance Affidavit.pdf 12/11/2025 at 9:18 am Ricky Zeng added file Invoice.pdf Ricky Zeng added file 12/11/2025 at 9:19 am Sign_Certification_Form_template_Tue_Jun_10_2025_09-29- 31.pdf to Record 1192945 12/11/2025 at 9:19 am Ricky Zeng submitted Record 1192945 OpenGov system altered approval step Community Development 12/11/2025 at 9:19 am Plan Review, changed status from Inactive to Active on Record 1192945 OpenGov system altered approval step Review for Completeness, 12/11/2025 at 9:19 am changed status from Inactive to Active on Record 1192945

OpenGov system assigned approval step Review for Completeness 12/11/2025 at 9:19 am to Branden Vigneault on Record 1192945 OpenGov system assigned approval step Community Development 12/11/2025 at 9:19 am Plan Review to Mason Wells on Record 1192945 Mason Wells reassigned approval step Community Development Plan Review from Mason Wells to Idelcia ReBeca Mapure on Record 12/11/2025 at 9:45 am 1192945 Mason Wells changed the deadline to Dec 25, 2025 on approval 12/11/2025 at 9:46 am step Community Development Plan Review on Record 1192945 Ricky Zeng added file Sign_Certification updated.pof to Record 12/12/2025 at 3:19 pm 1192945 Idelcia ReBeca Mapure altered multi-entry field Iliumination, 12/16/2025 at 11:03 am changed value from "Internal" to "External" on Record 1192945 Idelcia ReBeca Mapure added file 1 Park St_Approved Sign 12/16/2025 at 1:31 pm Certificate_20251216.pdf to Record 1192945 Idelcia ReBeca Mapure approved approval step Community 12/16/2025 at 1:35 pm Development Plan Review on Record 1192945 Ricky Zeng added a guest: [email removed] to Record 12/17/2025 at 10:45 am 1192945 Branden Vigneault approved approval step Review for Completeness 01/05/2026 at 5:32 pm on Record 1192945 OpenGov system altered approval step Department of Public Works 01/05/2026 at 5:32 pm Review, changed status from Inactive to Active on Record 1192945 OpenGov system assigned approval step Department of Public 01/05/2026 at 5:32 pm Works Review to Brian McLane on Record 1192945 Branden Vigneault altered multi-entry field Sign Text, changed value from "Love art Sushi" to "‹p style="box-sizing: border-box; margin: 01/05/2026 at 5:33 pm Opx Opx 10px"›Love Art Sushi ‹/p›" on Record 1192945 Branden Vigneault altered multi-entry field Projection from the 01/05/2026 at 5:37 pm Building (inches), changed value from ''' to "34" on Record 1192945 Brian McLane approved approval step Department of Public Works 01/08/2026 at 6:46 am Review on Record 1192945 OpenGov system altered approval step City Clerk Review, changed 01/08/2026 at 6:46 am status from Inactive to Active on Record 1192945 OpenGov system assigned approval step City Clerk Review to Lori 01/08/2026 at 6:46 am Perez on Record 1192945 Jessica Chiep added file AbuttersApproval.pdf to Record 1192945 01/08/2026 at 1:19 pm

Timeline Label Status Due Date Completed Assignee Activated / Review for 12/11/2025, Branden 1/5/2026, Completed - 5:32:45 PM 9:19:23 AM Completeness Vigneault Idelcia / Community 12/11/2025, 12/16/2025, Completed 12/25/2025 ReBeca Development 9:19:23 AM 1:35:15 PM Mapure Plan Review / Department Brian 1/8/2026, 1/5/2026, Completed of Public - McLane 6:46:26 AM 5:32:46 PM Works Review & City Clerk 1/8/2026, Active - Lori Perez Review 6:46:26 AM / City Inactive - Council - - - Approval Inactive - & Bond - - Ricky © Sign Permit Inactive - - Fee Zeng / Building Inactive - - - - Inspector Review Inactive - - - B Sign Permit

CITY 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 Inspectional 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: Ricky Zeng Phone: [phone removed] Email: [email removed] Sign Address: One Canal Park 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: Love Art Sushi Sign type: Projecting Sign (including awnings) Area in square feet: 9.62 L × 33" H Dimensions: 42" Placement height in feet: 10.5 Depth from façade: 7" Illumination: Internal Sign frontage in feet: 42.5 Area of existing signs to remain: COMMUNITY DEVELOPMENT DEPARTMENT CERTIFICATION FOR INTERNAL USE ONLY Sign conforms to requirements of Article 7.000: Choose option. Sign requires a variance from the Board of Zoning Appeals: Choose option. Comments: Signature: Adalcia Mapure Date CDD Representative CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

11000 NATURAL. ILLUMINATION - ANO EXTERNAL WITH CONDITONS INTERNAL ILLUMINATION SQFT MAX 30 STAN- 'SIGN ! FREE I DING ABOVE GROUND 2 SIGNS PER LOT FREESTANDING SIGN self-supporting structure and is not attached to any other structure. A free standing sign is attached to or part of a ONLY 5l EXTERNAL NATURAL AND ILEUMINATION- A LATER E BUILDING™ OF SIGNS PER SIGN FRONTAGE...- PARALLEL TO STREET _LENGTH OF BUILDING SQFT MAX 60 ABOVE WALL SIGN OVERVIEW BY SIGN TYPE sign area is parallel to the plane of the building. A wall sign is affixed so its exposed face and all APPROVE IF PROJECTION COUNCIL MUST EXCEEDS 6: CITY ABOVE PARALLEL TO STREET GROUND LENGTH OF BUILDING | SIGN FRONTAGE - SQ FT MAX 13 ONE SIGN PER GROUND FLOOR ESTABLISHMENT, CITY OF CAMBRIDGE • CDD ‹ SIGN CERTIFICATION APPLICATION ONEY NATURAL AND - EXTERNAL ILLUMINATION PROJECTING SIGN advertisement, announcement, or direction and which is designed to be seen from the outside of a building. For further information on specific 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 requirements, consult Article 7.000 of the Zoning Ordinance. awning mounted signs. a building face, including marquee, canopy, and A projecting sign is attached to and projects from

OFFICE OF THE CITY CLERK CAMBRIDGE CITY HALL, 795 MASSACHUSETTS AVENLE CAMBRIDGE, MASSACHUSETTS 02139 PHONE [phone removed] FAX [phone removed] TTY/TDD [phone removed] PAULA M. CRANE DONNA P. LOPEZ. DEPUTY CITY CLERK CITY CLERK ABUTTERS FORM FOR SIGN/AWNING PERMIT To Whom It May Concern: Date 12/18125 35 First Strat As Owner of Agent of Cambridge, of the approval Massachusetts, I do hereby declare my disapproval instaliment of: Canopy over the sidewalk entrance: Awnings over the windows: BLADE SEEN. I CAUSE PARK CAMBRIDGE MA 0Z14I Projecting sign: of said property. 12/29/25 Signed: Date Address: 125 Summer Street Boston, Ma. ABUTTERS: PLEASE COMPLETE FORM WHETHER OR NOT YOU APPROVE OF THE REQUESTED SIGN/AWNING AND RETURN IT TO THE APPLICANT WITHIN SEVEN (7) DAYS FOR INCLUSION IN THE APPLICATION. SIGN/AWNING APPLICANT: PLEASE FILL IN DATE THAT FORM WAS DELIVERED TO ABUTTER (TOP RIGHT OF THIS FORM)

NEW CC SIGN INC. Tel: [phone removed] SIGNAGE INVOICE Fax:[phone removed] 70 Old Colony Ave. Boston, MA 02127 15072 E-mail: [email removed] Address: CLIENT: Love Art Sushi 1 Canal Park Cambridge MA 02141 Telephone: Contact Person: [phone removed] Jessica Chiep Date: • Installation • Delivery • Pick-up 12/10/2025 LED Blade Sign $1650 Installation $450 TOTAL $ 2100 TAX $ PERMIT FEE $ DEPOSIT $ CASH → CHECK NO. BALANCE $ SIGNATURE OF CLIENT: Jusica DATE: 121012025 → CHECKNO. SIGNATURE OF THE SALES PERSON: Ricky Zeng DATE: 12/10/2025 DATE PAID IN FULL: Payment to be made as follows: 50% Deposit COLLECTED BY:

PROPERTY OWNER AUTHORIZATION FORM 1 Canal Owner, L.L.C. 1, (Property Owner's Name - Print) One Canal Park Owner of property located at New CC Sign Inc. / Ricky Zeng Hereby authorize (Company/Contractor's Name - Print) to at or nata roba ra buin perm dain is or is any a is beer ator zed representatives signature below. ature ву: Daniel Belldegrun, Authorized Signatory 11/24/2025 Date

Fax: [phone removed] [email removed] FART SUSHI LOVE TEL: [phone removed] / [phone removed] 259 Quincy Ave. Quincy, MA 02169 • NEW CC Sign ALL RIGHTS RESERVED NEW CC SIGN PROPOSAL Date This image is for general reference only, and may not accurately represent the actual product. Print Name The undersigned, in his or her individual and official capacity, hereby certies that the quoted prices, designs, specifications, terms, and conditions are accepted. New CC sign is authorized to perfom the work as specified. SIDE VIEW - „9z1 One Canal Park MA Cambridge Job No: Address: City: File Name: State/Zip: 33" TART LOVE SUSHI Love Art Sushi Jessica Chiep DIMENSIONS 040 Black aluminum box 1"x1" galvanized tubing frame Existing Bracket PRE-EXISTING CONDITIONS: Sign installed in location shown on attached photo SPECIFICATIONS Existing Lights 3/8" Clear acrylic lettering with white and red vinyl Box mounted on existing bracket [phone removed] Blade Sign: Customer: Estimate($0 Means No Price): Phone: Company: Original: 11/19/2025

CITY 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 Inspectional 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: Ricky Zeng Phone: [phone removed] Email: [email removed] Sign Address: One Canal Park 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: Love Art Sushi Sign type: Projecting Sign (including awnings) Area in square feet: 9.62 Dimensions: 42" H L × 33" Placement height in feet: 10.5 Depth from façade: 7" Illumination: Internal Sign frontage in feet: 42.5 Area of existing signs to remain: COMMUNITY DEVELOPMENT DEPARTMENT CERTIFICATION FOR INTERNAL USE ONLY Sign conforms to requirements of Article 7.000: Choose option. Sign requires a variance from the Board of Zoning Appeals: Choose option. Comments: Signature: Date CDD Representative CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

NATURAL AND EXTERNAL ILLUMINATION LINTH CONDIONIN" SQ FT MAX 30 DING STAN- SIGN : MAX. J 2 SIGNS PER LOT FREESTANDING SIGN any other structure. self-supporting structure and is not attached to A free standing sign is attached to or part of a SYTSANAL LUMINATION NATURAL AND BUILDING. UNUMITED $ OF SIGNS PER SIGN FRONTAGÉ - - PARALLEL-TO STREET _LENGTH OF BUILDING SQ FT MAX 60 ABOVE GROUND WALL SIGN OVERVIEW BY SIGN TYPE A wall sign is affixed so its exposed face and all sign area is parallel to the plane of the building. ¡ APPROVE IF PROJECTION COUNCIL MUST EXCEEDS 6", CITY ABOVE PARALLEL TO STREET GROUND LENGTH OF BUILDING * SIGN FRONTAGE - SQ FT MAX 13 ONE SIGN PER ESTARI ICUMENT GROUND FLOOR CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION ONLY • EXTERNAL NATURAL AND ILLUMINATION PROJECTING SIGN 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. 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 awning mounted signs. A projecting sign is attached to and projects from a building face, including marquee, canopy, and

CITY 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 Inspectional 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: Ricky Zeng Phone: [phone removed] Email: [email removed] Sign Address: One Canal Park 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: Love Art Sushi Sign type: Projecting Sign (including awnings) 9.62 Area in square feet: L H Dimensions: 42" × 33" 10.5 Placement height in feet: Depth from façade: 7" Illumination: Internal 42.5 Sign frontage in feet: Area of existing signs to remain: COMMUNITY DEVELOPMENT DEPARTMENT CERTIFICATION FOR INTERNAL USE ONLY Choose option. Sign conforms to requirements of Article 7.000: Sign requires a variance from the Board of Zoning Appeals: Choose option. Comments: Signature: Date CDD Representative CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION

AND EXTERNAT ILLUMINATION WITH CONDITONS INTERNAL ILLUMINATION 50 FT MAX 30 FREE STAN- SIGN ABOVE •COOLIND 2 SIGNS PER LOT FREESTANDING SIGN A free standing sign is attached to or part of a any other structure. self-supporting structure and is not attached to ONLY (a) EXTERNAL. NATURAL AND ILLUMINATION OF SIGNS PER BUILOING- UNLIMITED # SIGN FRONTAGE. PARALLEL-TO STREET _LENGTH OF BUILDING 5Q FT MAX 60 ABOVE GROUND WALL SIGN OVERVIEW BY SIGN TYPE sign area is parallel to the plane of the building. A wall sign is affixed so its exposed face and all ¡ APPROVE IF PROJECTION COUNCIL MUST EXCEEDS 6*, CITY SIGN FRONTAGE - ABOVE PARALLEL TO STREET GROUND LENGTH OF BUILDING ONE SIGN PER GROUND FLOOR ESTABLISHMENT. CITY OF CAMBRIDGE • CDD • SIGN CERTIFICATION APPLICATION NATURAL. AND ILLUMINATION - EXTERNAL PROJECTING SIGN Please note that this guide is intended to provide an overview of requirements by sign type. Sign shall mean and include any permanent or advertisement, announcement, or direction and which is designed to be seen from the outside of a building. For further information on specific temporary structure, device, letter, words, model, banner, pennant, insignia, trade flag, or representation used as, or which is in the nature of, an requirements, consult Article 7.000 of the Zoning Ordinance. a building face, including marquee, canopy, and awning mounted signs. A projecting sign is attached to and projects from

The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): New CC Sign Address: 259 Quincy Ave. Phone #: [phone removed] City/State/Zip: Quincy MA 02169 Are you an employer? Check the appropriate box: Type of project (required): 4. • I am a general contractor and I 1. D I am a employer with 2 6. • New construction have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7. Remodeling 2. D I am a sole proprietor or partner- These sub-contractors have • • Demolition 8. ship and have no employees employees and have workers' working for me in any capacity. 9. Building addition comp. insurance. [No workers' comp. insurance 10. Electrical repairs or additions 5. • We are a corporation and its required.] officers have exercised their 11.D Plumbing repairs or additions 3.L I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. 12. Roof repairs c. 152, $1(4), and we have no insurance required.] t 13.D Other Sign employees. [No workers' comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informatio Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suc Employees, that suck ohit actors a tapted eatey mal her she tie ename of tip ulcontactors and stale whether or not those entities have I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers Expiration Date: 12/24/2026 Policy # or Self-ins. Lic. #: UB-002W596558 Job Site Address: 1 Canal Park City/State/Zip: Cambridge MA 02141 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. Date: 12/11/2025 Signature: Ricky eng [phone removed] Phone #: Official use only. Do not write in this area, to be completed by city or town official. Permit/License # City or Town: Issuing Authority (check one): 10 Board of Health 2] Building Department 3D City/Town Clerk 4.L Electrical Inspector 5L Plumbing Inspector 6.OOther Phone #: Contact Person:

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), addresses) 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 CHY (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 Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111 Tel. [phone removed] or 1-877-MASSAFE Fax [phone removed] Revised 7-2019 www.mass.gov/dia