Fillable Town Of Barnastable Auto Dealer Application Form (Page 8 of 9) in pdf

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 your insurance company’s name, address and phone number along with a certificate 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). 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

1 Congress Street, Suite 100

Boston, MA 02114-2017

Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE

Fax # 617-727-7749

Form Revised 7/2013

Town Of Barnastable Auto Dealer Application Form Page 8

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