Fillable Town of Tisbury Tents or Temporary Structures Permit (Town of Tisbury)

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Town of Tisbury Tents or Temporary Structures Permit (Town of Tisbury)

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The Town of Tisbury Tents or Temporary Structures Permit (Town of Tisbury) form is 4 pages long and contains:

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  • 19 check-boxes
  • 55 other fields

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BROWSE TOWN OF TISBURY (MA) FORMS
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1
Town of Tisbury
Tents or Temporary Structures Permit
Application
Section 1: Site Information
1.1 Address where tent(s) or structures to be erected: 1.2 Assessor’s Parcel Number:
____________________________________________ ____________________________
Section 2: Applicant Information
Applicant’s Name: ______________________________________________________________
Contact Person: _____________________ Phone Number: ___________________________
Email Address: _________________________________________________________________
Section 3: Property Owner of Record Information
Owner’s Name: ________________________________________________________________
Owner’s Mailing Address: ________________________________________________________
Owner’s Phone Number: _________________________________________________________
Owner’s Email: _________________________________________________________________
Section 4: Type & Purpose of Tent or Temporary Structure
Type of Structure: _________________________________ Number of Structures: ______
Event Type & Purpose of Structure(s): ________________________________________________
_______________________________________________________________________________
Event Date: ____________ Set Up Date: ______________ Take Down Date: ______________
Section 5: Cooking & Gas Details
Caterer Name: ___________________________ Phone Number: ________________________
Number of Gas Cooking Appliances: _____ Number of Electric Cooking Appliances: ____
Type of Appliances: _______________________________________________________________
________________________________________________________________________________
Number of Propane Heaters: _____ Number of Electric Heaters: ____ BTUs: _____
Number of Propane Tanks: ______ Size of Tanks: ______
2
Section 6: Safety Details
Number of Fire Extinguishers on Hand: _________ Type: ___________________________
Indoor Lighting Used: Yes___ No ___ (check one) Lighting Type: ___________________________
Generator Used: Yes ___ No ___ (check one) Electrician’s Name: ___________________________
Structure Occupant Load: _____ Number of Tables: _____ Number of Chairs: _____
Number of Exits: _____ Number of Lighted Exit Signs: ______
Tent Certificate Number: ________________________________________
Section 7: Workers Compensation Insurance
A workers compensation insurance affidavit must be completed and submitted with this
application in accordance with M.G.L. ch. 152 & 25C(6). Failure to provide this affidavit will result
in the denial of your application.
Workers Compensation Affidavit Attached: Yes ____ No____ (check one)
Section 7: Owner Authorization for Agent or Contractor to Apply for Permit
I,__________________________________, as owner of the subject property hereby authorize
_____________________________________ to act on my behalf, in all matters relative to work
authorized by this building permit application.
Signature: ___________________________________________ Date: _______________
(Signed under the pains and penalties of perjury)
*ADDITIONAL PERMITS MAY BE REQUIRED FOR GAS OR WIRING WORK DEPENDING ON YOUR SETUP*
FOR OFFICE USE ONLY
Fire Department: Approved: ____ Denied: ____ Signature: _________________________
Board of Health: Approved: ____ Denied: ____ Signature: _________________________
Date Applied: _________________________ Date Approved: __________________________
Building Permit Number: ___________________
Signature: ____________________________________________
(Building Commissioner)
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_________________________________________________ _
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
†
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
‡
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers’ comp. policy number.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________
Job Site Address: City/State/Zip:______________________
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 (check one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing
Inspector 6. Other ______________________________
Contact Person:_________________________________________ Phone #:_________________________________
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13. Other____________________
1. I am a employer with _________
employees (full and/or part-time).*
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers’ comp. insurance
required.]
3. I am a homeowner doing all work
myself. [No workers’ comp.
insurance required.]
†
Are you an employer? Check the appropriate box:
4. I am a general contractor and I
have hired the sub-contractors
listed on the attached sheet.
These sub-contractors have
employees and have workers’
comp. insurance.
‡
5. We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers’
comp. insurance required.]
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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), address(es) 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 ______(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 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
www.mass.gov/dia
Revised 7-2019
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Town of Tisbury Tents or Temporary Structures Permit (Town of Tisbury)

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Completed 16 July 2020

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