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2/1/24, 8:26 AM Superior Court Civil Action Cover Sheet
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Massachusetts Trial Court
DOCKET NUMBER
CIVIL ACTION COVER SHEET The Superior Court
Help-Party information LON" ACM OOD AR P|COUNTY [Bristol Superior Court (Taunton)
Plaintiff Waters Technologies Corporation Defendant: » Pharmasol Corporation
ADDRESS: 34 Maple Street ADDRESS: One Norfolk Avenue
Milford, MA 01757 South Easton, MA 0237:
THIS UL, oS SUPENIOT VERT
Plaintiff Attorney: v Laws Office of Goldberg & Oriel Defendant Attorney: ¥ FLED
ADDRESS: Dana L. Skehan, Esq. ADDRESS:
199 Wells Ave, Ste. 209 FEB = a CUZ4
Newton, MA 02459
6803590 BBO: JENNIFER A. SULLA, CSG;
SEER + MARES TT Remove Pai
TYPE OF ACTION AND TRACK DESIGNATION (see instructions section on next page)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
A02 Good Sold & Delivered F © Yes @® No
*If “Other” please describe:
Is there a claim under G.L. c. 93A? Is there a class action under Mass. R. Civ. P. 23?
© Yes @® No © YES @ No
D BY GL.
|The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money dan
(Note to plaintiff: for this form, do not state double or treble damages; indicate single damages only.)
TORT CLAIM:
|A. Documented medical expenses to date
1. Total hospital expenses
2. Total doctor expenses
3. Total chiropractic expenses
4. Total physical therapy expenses
5. Total other expenses (describe below)
Subtotal (1-5): $0.00
B. Documented lost wages and compensation to date
C. Documented property damages to date
D. Reasonably anticipated future medical and hospital expenses.
E, Reasonably anticipated lost wages
F. Other documented items of damages (describe below)
TOTAL (A-F): $0.00
G. Briefly describe plaintiff's injury, including the nature and extent of the injury:
CONTRACT CLAIMS
© This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P, 8.1(a).
Item # Detailed Description of Each Claim Amount
1 Plaintiff sold and delivered goods at the Defendant's request. Defendant has failed to pay despite demand. $51,02¢
Total] $51,020
Add Claim Delete C
Signature of AtforneyiSelt Represented Plain X_} rer sk Deans —— | [Date: February 1, 202
RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court.
CERTIFICATION UNDER S.J.C. RULE 1:18/5)
https://courtforms.jud.state.ma.us/publicforms/SC0001 413
2/1/24, 8:26 AM Superior Court Civil Action Cover Sheet
--- wee sar
Ihereby certify that | have complied with requirements of Rule 5 of Supreme Judicial Court Rule 1
court-connected dispute resolution services and discuss with them the advantages and
Uniform Rules on Dispute Resolution, requiring that | inform my client
disadvantages of the various methods of dispute resolution.
Signature of Attorney: X LO)
$C0001: 1/13/2023
en Sc en Q
www.mass.govicourts
| [ Date: February 1, 202
Date/Time Printed:01-31-2024 1
CIVIL ACTION COVER SHEET INSTRUCTIONS —
SELECT A CATEGORY THAT BEST DESCRIBES YOUR CASE*
ACActions Involving
the State/Municipalityt” EREquitable Remedies RP Real Property
AAI Contract Action involving Commonwealth, (001 Specific Performance of a Contract (a) C01 Land Taking
Municipality, MBTA, etc. D02 Reach and Apply C02 Zoning Appeal, G.L. c. 404
AB1 Tortious Action involving Commonwealth, DO3 Injunction (F) C03 Dispute Concerning Title
Municipality, MBTA, etc. (A) D04 Reform/ Cancel Instrument (F) C04 Foreclosure of a Mortgage
AC1 Real Property Action involving DOS Equitable Replevin (F) COS Condominium Lien & Charges
Commonwealth, Municipality, MBTA etc. (A) DO6 Contribution or Indemnification F) C99 Other Real Property Action
‘AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust (A)
Municipality, MBTA, etc. (A) D08 Minority Shareholder's Suit (A) MC
Miscellaneous
Civil Action:
‘AE1 Administrative Action involvins O89 Interference in Contractual Relationship (F)
‘Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting £18 Foreign Discovery Proceeding
D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus
CN
Contract/Business
Cases D12 Dissolution of a Partnership (F) E22 Lottery Assignment, G.L. c. 10, § 28
D13 Declaratory Judgment, G.L. c. 231A, (A)
A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation (F) B Abuse/Harassment Preventic
‘A02 Goods Sold and Delivered (F) 1D99 Other Equity Action )
A03 Commercial Paper (F) £15 Abuse Prevention Petition, G.L. c. 209A
A04 Employment Contract (F) PA Givil Actions Involving Incarcerated
Party + 21 Protection from Harassment, G.L. c. 25€
‘A05 Consumer Revolving Credit - mr.cr. 3.1 (F)
A06 Insurance Contract (F) PA1 Contract Action involving an
A08 Sale or Lease of Real Estate (F) Incarcerated Party A)
12 Construction Dispute (A) PBI Tortious Action involving an E02 Appeal from Administrative Agency,
(4 Interpleader (F) Incarcerated Par (a)
BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E03 Certiorari Action, G.L. c. 249, § 4
Affairs of Entities (A) Incarcerated Party (F) E05 Confirmation of Arbitration Awards
BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E06 Mass Antitrust Act, G.L. c. 93, § 9
Officers, Partners, etc. (A) Incarcerated ) E07 Mass Antitrust Act, G.L. c. 93, § 8
BB1 Shareholder Derivative (A) PE1 Administrative Action involving an E08 Appointment of a Receiver
BB2 Securities Transactions (A) Incarcerated Party F) 09 Construction Surety Bond, G.L. c. 149,
BC1 Mergers, Consolidations, Sales of §§ 29, 290
Assets, Issuance of Debt, Equity, etc. (A) TR Torts £10 Summary Process Appeal
BD1 Intellectual Property (A) £11 Worker's Compensation
BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal
Secrets (A) Injury/Property Damage *) E17 Civil Rights Act, G.L. ¢.12, § 11H
BG1 Financial Institutions/Funds (A) B04 Other Negligence - Personal E24 Appeal from District Court.
BH1 Violation of Antitrust or Trade Injury/Property Damage (F) Commitment, G.L. 6.123, § 9(b)
Regulation Laws (A) BOS Products Liability (A) E94 Forfeiture, G.L. c. 265, § 56
A989 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical a) E95 Forfeiture, G.L. c. 94C, § 47
B07 Malpractice - Other ) 99 Other Administrative Action
* See Superior Court Standing Order 1-88 foran B08 Wrongful Death - Non-medical @ 01 Medical Malpractice - Tribunal only,
explanation of the tracking deadlines for each track B15 Defamation (A) GL. c. 231, § 608
designation: F, A, and X. On this page, the track B19 Asbestos (A) 202 Appeal Bond Denial
designation for each case type is noted in 1820 Personal Injury - Slip & Fall )
parentheses. B21 Environmental (F) ‘SO Sex Offender Review
B22 Employment Discrimination (F)
t’ Choose this case type if ANY party is the BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12
Commonwealth, a municipality, the MBTA, or any B99 Other Tortious Action ) £14 SDP Petition, G.L. c. 123A, § 9(b)
other governmental entity UNLESS your case is a
case type listed under Administrative Civil Actions RP Summary Process (Real Property) RCRestricted
Civil Actions
(AA).
‘S01 Summary Process - Residential (x) E19 Sex Offender Registry, G.L. c. 6, § 1788
Choose this case type if ANY party is an ‘802 Summary Process - Commercial E27 Minor Seeking Consent, G.L. ¢.112, § 1:
incarcerated party, UNLESS your case is a case Non-residential (F)
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97). TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
Bo3 Motor Vehicle Negligence-Personal
Injury 2 YES No
STATEMENT OF DAMAGES REQUIRED BY G.L. c. 212, § 3A
DUTY OF THE PLAINTIFF — On the face of the Civil Action Cover Sheet (or on attached additional sheets, if necessary), the plaintiff <
state the facts on which the plaintiff relies to determine money damages. A copy of the completed Civil Action Cover Sheet, including th
statement concerning damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, exce
otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant.
https://courtforms.jud.state.ma.us/publicforms/SC0001 213
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2/1/24, 8:26 AM Superior Court Civil Action Cover Sheet Save as PDF aD. Reset I Massachusetts Trial Court DOCKET NUMBER CIVIL ACTION COVER SHEET The Superior Court Help-Party information LON" ACM OOD AR P|COUNTY [Bristol Superior Court (Taunton) Plaintiff Waters Technologies Corporation Defendant: » Pharmasol Corporation ADDRESS: 34 Maple Street ADDRESS: One Norfolk Avenue Milford, MA 01757 South Easton, MA 0237: THIS UL, oS SUPENIOT VERT Plaintiff Attorney: v Laws Office of Goldberg & Oriel Defendant Attorney: ¥ FLED ADDRESS: Dana L. Skehan, Esq. ADDRESS: 199 Wells Ave, Ste. 209 FEB = a CUZ4 Newton, MA 02459 6803590 BBO: JENNIFER A. SULLA, CSG; SEER + MARES TT Remove Pai TYPE OF ACTION AND TRACK DESIGNATION (see instructions section on next page) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? A02 Good Sold & Delivered F © Yes @® No *If “Other” please describe: Is there a claim under G.L. c. 93A? Is there a class action under Mass. R. Civ. P. 23? © Yes @® No © YES @ No D BY GL. |The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money dan (Note to plaintiff: for this form, do not state double or treble damages; indicate single damages only.) TORT CLAIM: |A. Documented medical expenses to date 1. Total hospital expenses 2. Total doctor expenses 3. Total chiropractic expenses 4. Total physical therapy expenses 5. Total other expenses (describe below) Subtotal (1-5): $0.00 B. Documented lost wages and compensation to date C. Documented property damages to date D. Reasonably anticipated future medical and hospital expenses. E, Reasonably anticipated lost wages F. Other documented items of damages (describe below) TOTAL (A-F): $0.00 G. Briefly describe plaintiff's injury, including the nature and extent of the injury: CONTRACT CLAIMS © This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P, 8.1(a). Item # Detailed Description of Each Claim Amount 1 Plaintiff sold and delivered goods at the Defendant's request. Defendant has failed to pay despite demand. $51,02¢ Total] $51,020 Add Claim Delete C Signature of AtforneyiSelt Represented Plain X_} rer sk Deans —— | [Date: February 1, 202 RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court. CERTIFICATION UNDER S.J.C. RULE 1:18/5) https://courtforms.jud.state.ma.us/publicforms/SC0001 413 2/1/24, 8:26 AM Superior Court Civil Action Cover Sheet --- wee sar Ihereby certify that | have complied with requirements of Rule 5 of Supreme Judicial Court Rule 1 court-connected dispute resolution services and discuss with them the advantages and Uniform Rules on Dispute Resolution, requiring that | inform my client disadvantages of the various methods of dispute resolution. Signature of Attorney: X LO) $C0001: 1/13/2023 en Sc en Q www.mass.govicourts | [ Date: February 1, 202 Date/Time Printed:01-31-2024 1 CIVIL ACTION COVER SHEET INSTRUCTIONS — SELECT A CATEGORY THAT BEST DESCRIBES YOUR CASE* ACActions Involving the State/Municipalityt” EREquitable Remedies RP Real Property AAI Contract Action involving Commonwealth, (001 Specific Performance of a Contract (a) C01 Land Taking Municipality, MBTA, etc. D02 Reach and Apply C02 Zoning Appeal, G.L. c. 404 AB1 Tortious Action involving Commonwealth, DO3 Injunction (F) C03 Dispute Concerning Title Municipality, MBTA, etc. (A) D04 Reform/ Cancel Instrument (F) C04 Foreclosure of a Mortgage AC1 Real Property Action involving DOS Equitable Replevin (F) COS Condominium Lien & Charges Commonwealth, Municipality, MBTA etc. (A) DO6 Contribution or Indemnification F) C99 Other Real Property Action ‘AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust (A) Municipality, MBTA, etc. (A) D08 Minority Shareholder's Suit (A) MC Miscellaneous Civil Action: ‘AE1 Administrative Action involvins O89 Interference in Contractual Relationship (F) ‘Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting £18 Foreign Discovery Proceeding D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus CN Contract/Business Cases D12 Dissolution of a Partnership (F) E22 Lottery Assignment, G.L. c. 10, § 28 D13 Declaratory Judgment, G.L. c. 231A, (A) A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation (F) B Abuse/Harassment Preventic ‘A02 Goods Sold and Delivered (F) 1D99 Other Equity Action ) A03 Commercial Paper (F) £15 Abuse Prevention Petition, G.L. c. 209A A04 Employment Contract (F) PA Givil Actions Involving Incarcerated Party + 21 Protection from Harassment, G.L. c. 25€ ‘A05 Consumer Revolving Credit - mr.cr. 3.1 (F) A06 Insurance Contract (F) PA1 Contract Action involving an A08 Sale or Lease of Real Estate (F) Incarcerated Party A) 12 Construction Dispute (A) PBI Tortious Action involving an E02 Appeal from Administrative Agency, (4 Interpleader (F) Incarcerated Par (a) BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E03 Certiorari Action, G.L. c. 249, § 4 Affairs of Entities (A) Incarcerated Party (F) E05 Confirmation of Arbitration Awards BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E06 Mass Antitrust Act, G.L. c. 93, § 9 Officers, Partners, etc. (A) Incarcerated ) E07 Mass Antitrust Act, G.L. c. 93, § 8 BB1 Shareholder Derivative (A) PE1 Administrative Action involving an E08 Appointment of a Receiver BB2 Securities Transactions (A) Incarcerated Party F) 09 Construction Surety Bond, G.L. c. 149, BC1 Mergers, Consolidations, Sales of §§ 29, 290 Assets, Issuance of Debt, Equity, etc. (A) TR Torts £10 Summary Process Appeal BD1 Intellectual Property (A) £11 Worker's Compensation BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal Secrets (A) Injury/Property Damage *) E17 Civil Rights Act, G.L. ¢.12, § 11H BG1 Financial Institutions/Funds (A) B04 Other Negligence - Personal E24 Appeal from District Court. BH1 Violation of Antitrust or Trade Injury/Property Damage (F) Commitment, G.L. 6.123, § 9(b) Regulation Laws (A) BOS Products Liability (A) E94 Forfeiture, G.L. c. 265, § 56 A989 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical a) E95 Forfeiture, G.L. c. 94C, § 47 B07 Malpractice - Other ) 99 Other Administrative Action * See Superior Court Standing Order 1-88 foran B08 Wrongful Death - Non-medical @ 01 Medical Malpractice - Tribunal only, explanation of the tracking deadlines for each track B15 Defamation (A) GL. c. 231, § 608 designation: F, A, and X. On this page, the track B19 Asbestos (A) 202 Appeal Bond Denial designation for each case type is noted in 1820 Personal Injury - Slip & Fall ) parentheses. B21 Environmental (F) ‘SO Sex Offender Review B22 Employment Discrimination (F) t’ Choose this case type if ANY party is the BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12 Commonwealth, a municipality, the MBTA, or any B99 Other Tortious Action ) £14 SDP Petition, G.L. c. 123A, § 9(b) other governmental entity UNLESS your case is a case type listed under Administrative Civil Actions RP Summary Process (Real Property) RCRestricted Civil Actions (AA). ‘S01 Summary Process - Residential (x) E19 Sex Offender Registry, G.L. c. 6, § 1788 Choose this case type if ANY party is an ‘802 Summary Process - Commercial E27 Minor Seeking Consent, G.L. ¢.112, § 1: incarcerated party, UNLESS your case is a case Non-residential (F) type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? Bo3 Motor Vehicle Negligence-Personal Injury 2 YES No STATEMENT OF DAMAGES REQUIRED BY G.L. c. 212, § 3A DUTY OF THE PLAINTIFF — On the face of the Civil Action Cover Sheet (or on attached additional sheets, if necessary), the plaintiff < state the facts on which the plaintiff relies to determine money damages. A copy of the completed Civil Action Cover Sheet, including th statement concerning damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, exce otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant. https://courtforms.jud.state.ma.us/publicforms/SC0001 213