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CITY OF SOMERVILLE APPLYING FOR A HOST COMMUNITY (City of Somerville)

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CITY OF SOMERVILLE
i
Posted February 13, 2019 | Revised March 6, 2019 | Revised July 31, 2019 (changes tracked in red)
Mayor’s Office of Strategic Planning and Community Development | City Clerk’s Office
APPLYING FOR A HOST COMMUNITY AGREEMENT (HCA) AND LICENSE TO
OPERATE AN ADULT-USE MARIJUANA ESTABLISHMENT
Pursuant to MA General Law Chapter 94G Section 3 and Municipal Ordinance Chapter 2 Section 2-221,
any marijuana establishment seeking to operate in Somerville must execute a Host Community
Agreement (HCA). The HCA sets forth the conditions to have a marijuana establishment located within
the City which includes, but is not limited to, all stipulations of responsibilities between the host
community and the establishment. In addition to the HCA, the establishment must be issued a city
license from the Licensing Commission and a special permit from the Special Permit Granting Authority.
To streamline the application process, the City of Somerville has created one application packet for both
the HCA and city license. This packet includes a copy of the application and provides detailed
information on the application process. For a copy of this application, zoning ordinance and overlay,
licensing ordinance, and other materials related to adult-use marijuana, please visit the City of
Somerville website at: https://www.somervillema.gov/adult-marijuana.
Conditions for Operating a Marijuana Establishment
1. The business applicant (“Applicant) must be approved for and execute a host community
agreement (HCA) with the City.
2. The Applicant must be approved for a city license by the Somerville Licensing Commission.
3. The premises and the use must be approved by the Special Permit Granting Authority (SPGA),
pursuant to the City’s building and zoning codes.
4. The Applicant must conduct community outreach meetings and appear at public hearings as
required by the SPGA and Licensing Commission.
5. The Applicant and all owners must have paid all taxes, fees and fines owed to the City.
6. The Applicant must be licensed by the MA Cannabis Control Commission (CCC).
7. The license is not transferrable without the approval of the MA CCC and the Licensing
Commission.
8. Until November 8, 2020, the City may issue no more than 12 Marijuana Retailer Licenses.
9. Until November 8, 2020, the City may issue Marijuana Retailer Licenses to only Priority Group A
and Priority Group B Applicants.
Priority Group A: An Economic Empowerment Applicant; an Applicant owned by a Somerville
resident or an entity with a majority (> 50%) of its ownership made up of Somerville residents;
or a cooperatively owned Applicant.
Priority Group B: A Registered Marijuana Dispensary (RMD) currently operating in the City
that will continue selling medical marijuana products in the City.
10. Until November 8, 2020, the City may issue Marijuana Retailer Licenses to Priority Group B
Applicants if the number of then-licensed Priority Group B Applicants will be equal to or less than
the number of then-licensed Priority Group A Applicants.
ii
Posted February 13, 2019
Mayor’s Office of Strategic Planning and Community Development | City Clerk’s Office
Application Components and Submittal Process
1. The Applicant completes the Marijuana Establishment Host Community Agreement (HCA) and
License Application (“Application”). The Application consists of seven (7) sections:
Section 1. Business Information, Business Type, Establishment type
Section 2. Priority Status
Section 3. Operating Information
Section 4. Compliance Information
Complete one form for each owner with a 10% or greater ownership stake in the company
Section 5. Property Owner’s Certification and Authorization
Complete one form for each property owner
Section 6. Applicant’s Certification, Acknowledgement, Release and Indemnification, and
Wage Theft Statement
Section 7. Worker’s Compensation Insurance Affidavit
2. In addition to completing the Application, the following materials are required:
a. A non-refundable application fee of $900 made payable to the City of Somerville
Note: fee will be waived for all applicants through April 1
st
, 2020
b. Site plans (e.g. aerial image, plot plan, and conceptual floor plan)
c. Elevations (e.g. photograph of existing elevations, graphic simulation of proposed
elevations)
d. Drafts of the three packets required by the MA Cannabis Control Commission (CCC):
i. Application of Intent packet
ii. Background Check packet
iii. Management and Operations Profile packet
3. The Application and all required materials must be submitted as PDF files.
a. The Application and required materials can be emailed to Alex Mello, the Mayor’s Marijuana
Advisory Committee (MAC) liaison, at amello@somervillema.gov.
b. The Application and required materials can also be submitted via USB drive or CD in person
to Alex Mello:
Mayor’s Office of Strategic Planning and Community Development (OSPCD)
Somerville City Hall, 3
rd
floor
93 Highland Ave, Somerville, MA 02143
Review and Approval Process
1. The City of Somerville’s Marijuana Advisory Committee (MAC) will review all applications. Four
municipal officials will serve on the MAC:
Sarah Lewis, Planning Director
Douglas Kress, Director of Health and Human Services
Stephen Carrabino, Deputy Police Chief
Thomas Galligani, Director of Economic Development
iii
2. The MAC will evaluate each proposal in three categories:
Location: location within an approved district, appropriate/best use of space, and
appropriate access
Physical Space: proposed plan respects surrounding area, flow of operations, crime
prevention through environmental design strategies (CPTED), and security
Operations: proposed operations that focus on security, community education, hiring of
local residents, and partnerships with local businesses
Applicants can receive a score from 1 – 5 (1 being the lowest score and 5 being the highest score), in
each of the categories based on the Applicant’s responses.
3. The MAC may also conduct interviews of Applicants.
4. Based on the application evaluation and interviews, the MAC will prepare recommendations to the
Mayor’s Office on which applicants should proceed with the HCA process.
5. The City will issue an HCA to Applicants who are recommended by the MAC and approved by the
Mayor; the Applicant and Mayor sign the HCA.
6. After executing the HCA, the Applicant will move forward in the licensing and special permits
process. There may be additional fees or materials required for review by the Licensing Commission
or Special Permits Granting Authority (SPGA).
a. Licensing: The Licensing Commission reviews the application, conducts a public hearing,
and grants the license
b. Special Permits: The SPGA reviews the application, conduct a public hearing, and
approves the special permit
7. The Applicant completes the Massachusetts CCC Application process.
8. After receiving a complete application from the CCC, the MAC reviews it within 60 days and certifies
to the CCC that the application is compliant with all municipal and zoning ordinances.
9. The CCC issues a provisional license to the applicant.
10. The applicant builds out the space.
11. The City’s Inspectional Services Department issues a Certificate of Occupancy to the Applicant; the
Licensing Commission issues the City License.
12. The Applicant provides the Certificate of Occupancy and the City License to the CCC.
13. The CCC issues the final license to operate.
Application Review Schedule
The MAC will review applications on a monthly basis. Complete applications, with all required
attachments, must be submitted by 12:00pm on the first Friday of the month to be considered for
review. Applications submitted after the first Friday of the month will be held until the next review cycle.
[Edited 7/31/19 to clarify review schedule]
iv
Questions
If you have questions about the MAC, contact Alex Mello, the MAC liaison, at
amello@somervillema.gov. Questions will only be accepted via email. Responses to emails from
potential applicants will be made available to other potential applicants while protecting the
confidentiality of the person asking the original question
Required Document Checklist
Please ensure all application materials, including attachments, are complete before
submitting. Incomplete packets will be returned to the Applicant and will not be reviewed
by the MAC.
Application
Business Information
Priority Status Documentation
Operating Information Narrative
Compliance Information (1 form per business owner with at least a 10% stake)
Property Owner’s Certification and authorization
Applicant’s Certification, Acknowledgement, Release, and Indemnification, and Wage
Theft Statement
Workers’ Compensation Insurance Affidavit
Application Fee ($900) Note: Fee will be WAIVED for all applicants through April 1
st
, 2020
Check or money order made payable to the City of Somerville
Site Plans (draft plans are acceptable)
May include: aerial image, plot plan, and conceptual floor plan
Elevations (draft plans are acceptable)
May include: photograph of existing elevations, graphic simulation of proposed
elevations
Drafts of the three packets required by Massachusetts Cannabis Control Commission (CCC)
Application of Intent Packet
Background Check Packet
Management and Operations Profile Packet
CITY OF SOMERVILLE
1
MARIJ
UANA ESTABLISHMENT HOST COMMUNITY AGREEMENT (HCA) AND
LICENSE APPLICATION
Section 1. Business Information:
Business Legal Name:
Business DBA, if different:
Business Address:
Phone: Website: ______
Federal Employer Identification Number (EIN):
Does the business currently possess any type of marijuana license in Somerville? ☐Yes ☐No
If yes, describe:
Primary Contact Name:
Mailing Address:
Email: Phone:
Emergency Contact Name:
Email: Phone:
If y
ou would like mail to be sent to a different address, provide alternate mailing information below:
Mailing Contact Name:
Mailing Address:
2
Type of Business
Check only one and provide names as indicated:
☐Sole Proprietor: Name of Owner:
☐Partnership (inc. LLP): Name of Partnership:
Names of All Partners Who Own More Than 10%:
☐Trust: Name of Trust:
Names of All Trustees Who Own More Than 10%:
☐Corporation: Name of Corporation:
Name of President:
Name of Secretary:____________________ Name of Treasurer:
☐LLC: Name of LLC:
Names of All Managers Who Own More Than 10%:
☐Other (Attach a Description of the Form of Ownership and the Names of Owners
Type of Establishment
Select all that apply:
Marijuana Retailer
Marijuana Cultivator
Craft Marijuana Cooperative
Marijuana Product Manufacturer
Independent Testing Laboratory
Marijuana Research Facility
Other: Describe
3
Section 2. Priority Status
For Marijuana Retailers Only
☐Group A Priority. Attach proof that the applicant is 1) an Economic Empowerment Applicant, 2) is
owned by Somerville resident(s) or entities with at least 50% of its ownership made up of Somerville
residents, or 3) is a cooperatively-owned entity.
A
n Economic Empowerment Applicant is one who meets at least 3 of the following criteria:
1) A majority of ownership belongs to people who have lived for 5 of the preceding 10 years in an
area of disproportionate impact, as determined by the MA CCC
;
2) A
majority of ownership has held one or more previous positions where the primary population
served were disproportionately impacted, or where primary responsibilities included economic
education, resource provision or empowerment to disproportionately impacted individuals o
r
c
ommunities;
3) At least 51% of current employees or subcontractors reside in areas of disproportionate impact
and by the first day of business, the ratio will meet or exceed 75%;
4) At least 51% of employees or subcontractors have drug-related CORI and are otherwise legally
employable in cannabis enterprises;
5) A majority of ownership is made up of individuals of Black, African American, Hispanic or Latino
descent;
6) Other significant articulable demonstration of past experience in or business practices tha
t
promote economic empowerment in areas of disproportionate impact.
☐
Group B Priority. Attach proof that your company is a Registered Marijuana Dispensary currently
operating in Somerville that will continue selling medicinal products.
☐
No Priority. All applicants who are not Group A or B should check here.
4
Section 3. Operating Information
The following section asks you to describe your business operations and alignment with
the city’s values. For each question, please be as specific as possible. You may attach
additional pages to respond to these questions if needed.
1. Describe how the Applicant will help monitor the health impacts of recreational marijuana in
their neighborhood and on local youth.
2. Describe how the Applicant will prevent and educate youth and families about the dangers of
underage exposure to, and the consumption of, recreational marijuana. Describe how the
Applicant will sustain these efforts over time.
3. Describe how the Applicant will inform customers about restrictions on public consumption and
workplace use, the risks of second-hand smoke, and dangers of operating a motor vehicle while
impaired.
4. Describe how the Applicant will market its products, including, but not limited to, broadcast,
print, and online advertising, direct-response advertising, social media, and signage.
5. Describe the sources of the Applicant’s inventory or manufacturing materials.
6. Describe how the Applicant will package and label products at the point of sale.
7. Describe who the Applicant will employ, and the wages and benefits that will be provided
5
8. Describe how the Applicant will use sustainable green practices and renewable energy sources.
9. Describe how the Applicant will further each of these Somerville values.
a. Celebrating the diversity of our people, cultures, housing and economy.
b. Fostering the unique character of our residents, neighborhoods, hills and squares, and
the strength of our community spirit as expressed in our history, our cultural and social
life, and our deep sense of civic engagement.
c. Investing in the growth of a resilient economic base that is centered around transit,
generates a wide variety of job opportunities, creates an active daytime population,
supports independent local businesses, and secures fiscal self-sufficiency.
d. Promoting a dynamic urban streetscape that embraces public transportation, reduces
dependence on the automobile, and is accessible, inviting and safe for all pedestrians,
bicyclists and transit riders.
e. Building a sustainable future through strong environmental leadership, balanced
transportation modes, engaging recreational and community spaces, exceptional
schools and educational opportunities, improved community health, varied and
affordable housing options, and effective stewardship of our natural resources.
f. Committing to continued innovation and affirmation of our responsibility to current and
future generations in all of our endeavors: business, technology, education, arts and
government, including your neighbors (within 300 feet), City youth, and the City as a
whole.
6
Section 4. Compliance Information
Each individual (e.g. partner, trustee, manager) with a 10% or greater ownership stake in
the business must complete a separate copy of this form.
Owner’s Name:________________________________________ Ownership Stake (%)______________
1. Has the Owner ever obtained a marijuana-related license in any ☐Yes ☐No
jurisdiction?
If yes, explain:
2. Has the Owner ever had any type of license denied, revoked or suspended ☐Yes ☐No
in any jurisdiction?
If yes, explain:
3. Has the Owner ever received a Notice of Violation in any jurisdiction? ☐Yes ☐No
If yes, explain:
4. Has the Owner been in compliance for the last 3 years (or since being in ☐Yes ☐No
business in Massachusetts, whichever is less), and is the applicant currently
in compliance, with all laws and regulations of the State of Massachusetts?
If no, explain:
5. Has the Owner been in compliance for the last 3 years (or since being in ☐Yes ☐No
business in Somerville, whichever is less), and is the applicant currently
in compliance, with all laws and regulations of the City of Somerville?
If no, explain:
6. Has the Owner been charged in any jurisdiction with any form of wage theft in ☐Yes ☐No
the last 3 years?
If yes, explain:
7
Section 5. Property Owner’s Certification and Authorization:
If the property has more than one owner, each owner must sign a copy of this form:
Street Address of Business Location:
Zoning District and Overlay District, if any:
Assessor’s Map______ Block______ Lot______ Ward________________________
Property Owner’s Legal Name:
Property Owner’s Mailing Address (with zip code):
Property Owner’s Type of Business (Check Only One and Provide the Names Indicated):
☐Sole Proprietor: Name of Owner:
☐Partnership (inc. LLP): Name of Partnership:
Names of All Partners Who Own More Than 10%:
☐Trust: Name of Trust:
Names of All Trustees Who Own More Than 10%:
☐Corporation: Name of Corporation:
Name of President:
I certify that:
I am the property owner or that I am duly authorized to act as an agent for the property owner,
for the property located at .
______________________________ (legal name of Applicant) has been authorized by me to
develop and use the property listed above for the purposes indicated in this application.
I will permit any officials representing the City to conduct site visits on the property in
connection with this Application and, if approved, this Applicant’s business.
Should the ownership of this property change before the City has acted on this Application, I w
ill
provide updated information and new copies of this signature page.
Owner Signature: Date:
Print Name:
Title (Owner, President, Agent, Etc.):
Email: Phone:
8
Section 6. Applicant’s Certification, Acknowledgment, Release and
Indemnification, and Wage Theft Statement
I certify that I am the Applicant or that I am duly authorized to act as an agent for the Applicant.
I certify that all of the information on this application is true and accurate, and that any information
found to be false or misleading will result in the forfeiture of this license and may result in a one-year
wait before a new application can be submitted, as well as criminal prosecution.
I certify that I will make no changes to any component of the business plan described in this application
without written notification to, and the prior approval of, the City.
I acknowledge that any violation of the City’s ordinances, regulations, and conditions pertaining to this
license could subject me and anyone operating under this license to arrest, fine, and loss of this license.
I release, discharge and hold harmless, the City of Somerville, a municipal corporation of the
Commonwealth of Massachusetts, and its officers, employees, agents and servants from all actions,
causes of action, claims, demands, damages, costs, loss of services, expenses and compensation
associated with the issuance of this license.
I certify that the Applicant, to my best knowledge and belief, has filed all State tax returns and paid all
State taxes required under law.
I certify that the Applicant has not been found guilty, liable or responsible, in any judicial or
administrative proceeding, of committing or attempting to commit a violation of any of the laws set
forth in Municipal Ordinance 9-31, the “Wage Theft Ordinance”, which appears below.
Signature: Date:
Print Name:
Title (Owner, President, Agent, Etc.):
Email: Phone:
Sec. 9-31. - Wage theft.
(a) The city, by and through its officials, boards and commissions, may deny an application for any license or permit issued by it, if, during the three-year period
prior to the date of the application, the applicant admitted guilt or liability or has been found guilty, liable or responsible, in any judicial or administrative proceeding,
of committing or attempting to commit a violation of: (1) Commonwealth of Massachusetts Payment of Wages Law, General Laws Chapter 149, Section 148, and
any and all other state or federal laws regulating the payment of wages, including, but not limited to, Chapter 149, Sections 27, 27G, 27H, 52D, 148A, 148B,
150C, 152, 152A, 159C; and Chapter 151, sections 1, 1A, 1B, 15, 19 and 20 of the General Laws; and (2) The Fair Debt Collection Practices Act, 15 U.S.C.
§1692, or any other federal or state law regulating the collection of debt, as to the employees of the applicant or others who had performed work for said applicant.
— (b) Any license or permit issued by the City of Somerville, its boards or commissions, may be revoked or suspended if, during the three years prior to the
issuance of the license or permit, the licensee or permittee admitted guilt or liability or has been found guilty or liable in any judicial or administrative proceeding of
committing a violation of any of the laws set forth in subsection (a) above. — (c) Any license or permit issued by the City of Somerville, its boards or commissions,
may be revoked or suspended if the applicant, licensee or permittee is a person who was subject to a final judgment or other decision for violation of any of the
laws set forth in subsection (a) above within three years prior to the effective date of this section, and the judgment was not satisfied within the lawful period for
doing same, or the expiration of the period for filing an appeal; or if an appeal is made, the date of the final resolution of that appeal and any subsequent appeal
resulting in a final administrative or judicial affirmation of violation of any of the laws set forth in subsection (a) above. — (d) The period of non-issuance, revocation
or non-renewal shall be one year, and the licensee or permittee or the person who is the principal of a license or permit shall not again be licensed or permitted in
any other manner during such period. — (e) Within 14 calendar days from the date that the notice of refusal to issue, revocation or refusal to renew notice is
mailed to the applicant or licensee or permittee, the applicant, licensee or permittee may appeal such decision by filing a written notice of appeal setting forth the
grounds therefor. Said notice shall be sent by certified mail, return receipt requested. The hearing shall be conducted by the board, commission or individual who
made the decision not to issue, not to renew, or to revoke within 30 days of receipt of such notice of appeal. — (f) An applicant for a business certificate, license or
permit shall be provided with a copy of the ordinance from which this section derived and shall certify that he has not been found guilty, liable or responsible, in
any judicial or administrative proceeding, of committing or attempting to commit a violation of any of the laws set forth in subsection (a) above. — (g) This law shall
apply to any person or entity whose final administrative decision or adjudication or judicial judgment or conviction was entered on or after July 1, 2013, with the
exception of judgments that remain unsatisfied as set forth in subsection (c) above. — (h) Application of this section is subject to applicable state or federal laws.
Applicant Information Please Print Legibly
Business/Organization Name:_________________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information.
Insurance Company Name:______________________________________________________________________________
Insurer’s Address:_____________________________________________________________________________________
City/State/Zip: ________________________________________________________________________________________
Policy # or Self-ins. Lic. # Expiration Date:
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: Date:
Phone #:
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. B
oard of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen’s Offi
ce
6.
Other ________
_______________________
Contact Person:_________________________________________ Phone #:_________________________________
1. I am a employer with _________ employees (full and/
or part-time).*
2. I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers’ comp. insurance required]
3. 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. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers’ comp. insurance req.]
Are you an employer? Check the appropriate box:
Business Type (required):
5. Retail
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. Entertainment
10. Manufacturing
11. Health Care
12. Other _____________________________
www.mass.gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Section 7. Worker's Compensation Insurance Affidavit
Information and Instructions
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 Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
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.
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CITY OF SOMERVILLE APPLYING FOR A HOST COMMUNITY (City of Somerville)

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