20.084 Menard Wage ComplianceCity of Northampton
AFFADAVIT OF WAGE COMPLIANCE
Name of Business: Norman E. Menard
Location of Business: 25 Garfield Avenue
The Northampton City Council, in determining whether to issue, re -issue, modify, suspend or revoke a
license. under G.L. c. 140,shall require that a potential or current licensee certify that they are not
subject to a federal or state criminal or civil judgment, administrative citation, order or final
administrative determination resulting from a violation of G.L. c.149, c. 151, or the Fair Labor Standards
Act The City Council may require a wage bond or insurance be posted by any potential licensee who
does not certify that they are not subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c. 149, c. 151, or
the Fair Labor Standards Act. Licensees that are subject to a state or federal debarment for violation of
the above laws, either voluntarily or involuntarily, or that have been prohibited from contracting with
the Commonwealth or any of its agencies or subdivisions shall be prohibited from holding, or continuing
to hold, licenses issued under G.L. c. 140, for the entire period of debarment or other stated time
period.
Applicants must check box 1 or box 2 as applicable and must sign this Form, certifying compliance
with the requirements set out in this Form. This Form must be included with the application.
AFFADAVIT: N) (Choose 1 below)
This License aoolicant is not
r state criminal or civil judgment,
administrative citation, order or final administrative determination resulting from a violation of
G.L. c.149, c. 151, or the Fair Labor Standards Act within the last three years.
❑ This License applicant is subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c.149, c.
151, or the Fair Labor Standards Act within the last three years. This applicant will provide a
wage bond or wage insurance for the period of the license.
(Typed or printed name of applicant)
(V)-. �� e 191--4 �-
(Signature)