12/1/1981 BOARD OF SELECTMEN Minutes

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. r ..p 7 F. 1. _MASSACHUSETTS DIVISION OF INDUSTRIAL ACCIDENTS p� ✓o`, • �STANDARD FORM FOR � S_ 1 81 � EMPLOYER'S FIRST REPORT OF INJURY Numbte's Carrier: arF,ler Number Carnes Aoars•cd by 1. A. 1. A. e. e. For Employer: - c Within 48 fours after the occurrence of an accident, forward this -eport to the Industrial Accident Board, State Office Building, Cos<rn- Carrier's File No. nent Center, 100 Cambridge Street, Boston, Massachusetts 022flI! (The spaces above not to be filled in by Employer) (PRINT OR TYPE) 1. Name of Employer Town of Mashpeen - 2. Office address: No. and St.L.An+rAlROad City or Town Mashp P State MA 3. (a) State name of insurance company with when you are insured to provide payment to injured employees under the Wmk- Player men's Compensation Act Ib) If not so insured, give number of employees on date of this report 4. Give nature of business (or article manufactured) 1N,..,i Ci 1221 i ty t1 5- (a) Location of plant Highway Department MeetinghOuGeRoad Ib) Ptace where injury occurred rA-_ragepp�� Ic) State if injury occurred on or off employer's premises M 6. Data of injury Novemher O, 19 HI Day of week Fr1�Hour of day_A. M.2L.nP. M d Nnvcm 19 A. M � R M. 8. Was injured paid in full for this day�,- 7. Date disability began iter 291 81— 2 9. When did you or foreman first know of injury? 4O M 10. Name of foreman Burl eyGre.ene , Jr. 11. Name of injured RQger A Medel rfl3 (nwsT NAME) - (Mtooca 1N11nALI ("ST NAME) 12. Address: No. and St. City or Town '^'_Falmouth State MA 13. Check (�./) Marrird— Single , Widowed Widower , Divorced Male—X Female_ 14. Age 34 Did you have on file employment certificate or permit p,,,. jured 15. (a) Occupation when injured Menh ni e (b) Was this his or her regular occupation eG rsew (If not, state in what department or branch of work regularly employed) 16. Ia) How long employed by you_-5 ye_arc Ib) Piece or time worker_t1Mle_(c) Wages per hour S 17. let No. hours worked per day 8 (b) Wages per day $ 48 76 (C) No. days worked per week 5 (d1 Average weekly earnings S 244 -80 le) Where applicable give number of meals furnished employee each week, and estimated value per day, week, or month of any lodging, fuel or other advantages fumisf.ed employee 18. Machine, tool or thing causing injury f_.s�son'+�� IQQ}^ 19. Kind of power (hand, foot, electrical, steam, etc.) 20. Part of machine on which accident occurred 21, (a) Was safety appliance or regulation provided Ib) Was it in use at time 22. Was accident caused by injured's failure to use or observe safety appliance or regulation No gab 23. Describe fully hew accident Occurred, and state what sswptuyee was doing, when inivred Re was kueel ing jury to get up-hi-i-right Oe 24. Names and addresscsof witnesses Helen Kondoehriste. 14 Starboard Lane, Maahpee 25. Nature and location of injury Iee dscc�ribee fully etas location of amputations or fractures, right or left) Right-- P lovirteled- 26. Probable length of disabi ay hail ny m 27. Has injured returned to work 110 If so, date and `o At what wage $ jury 28. At what occupation 29. Name and address of physician Dr. Richard M Pearstein, 342Gifford St. . Falmouth, (b) Name and aedmss of hospital Fa1 m cath HneTri 4a1. Ter Henn Drive MA.