HomeMy WebLinkAbout2018-19The Commonwealth of Massachusetts Fee
Town of Yarmouth $150.00
HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS
Number: BOHHM-17-1233-01
Mailing Address:
FEDEX CORPORATION
FEDEX EXPRESS - HYAA
BLDG B 3RD FLOOR
3620 HACKS CROSS RD
MEMPHIS, TN 38125-8800
Issue Date: 7/1/2018
Location Address:
60 ANSEL HALLET RD
WEST YARMOUTH, MA 02673
IS HEREBY GRANTED A 2018-2019 LICENSE
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires June 30, 2019 unless sooner suspended or revoked and is not transferable.
Conditions
Yarmouth Board of Health Hazardous Materials Regulation, Section 12A: Must report any spills over
one gallon in size to the Health and Fire departments.
1) The annual report is to be submitted to the Board of Health by June 1 including the items listed under
"Federal Express Annual Report Requirements (Modified at Board of Health Hearing of 10-20-2014)"
2) Nitrate loading deed restriction: 396 square foot lawn area.
3) Maximum occupancy is 56 people.
4) No use of use of ice melt chemicals. Only sand is allowed.
5) Any toxic or hazardous waste generated at the site is to be removed within 90 days.
6) In the event FedEx no longer operates the facility all vehicle wash water tanks are to be emptied within 7
days of the termination of site
operation.
7) No underground storage of any material deemed toxic or hazardous by the Board of Health.
8) There shall be no major vehicle repair.
Board
of
Health
Hillard Boskey, M.D., Chairman
Mary Craig, Vice Chairman
Charles T. Holway, Clerk
Debra Bruinooge
Paul M. O'Bryan, PhD
Bruce G. Murphy, MPH, R.S., listant
/ Amy L. von Hone, R.S., CHO
Health Director / Health Director
rr, TOWN OF YARMOUTH BOARD OF HEALTH
2018/19 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICE+
APPLICATION
PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY
JUNE 15, 2018
PLEASE COMPLETE ALL QUESTIONS
NAME OF BUSINESS
BUSINESS ADDRESS LP 0
MAILING ADDRESS
EMAIL ADDRESS
LICENSE _
FEE: $150.00
BUSINESS TEL. # ab 1 43 3WO
MANAGER/CONTACT PERSON GY-61 Q `Ne-1 1 HOME TEL.
OWNER NAME
HOME ADDRESS
HOME TEL. #
CORPORATION NAME (IF APPLICABLE) re[] & 0o1Q=-h M TEL. #
CORPORATION ADDRESS "� t� L,f (� BI c b �3 F1UzY
MAILING ADDRESS
TAX ID (FEIN OR SSN)
LICENSES RUN ANNUALLY FROM JULY 1 TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
TO REOPENING.
Town of Yarmouth taxes and liens must be paid prior to renewal , issuance of your permits. Please check appropriately
if paid: yes no n/a �id usle -
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any license
or permit to operate a business if a person or company does not have a Certification of Workers Compensation insurance.
As part of renewal or issuance of your permits, you must complete the enclosed Workers Compensation Affidavit. If
not applicable, please explain:
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ON FILE
Y N
Y N
ANY NEW CHEMICALS MUST BE PRE -APPROVED BY THE HEALTH DEPARTMENT.
RENEWAL APPLICATION X NEW APPLICATION
APPLICANT'S SIGNATURE
DATE 6 ~ 1 C1 — I9
The Commonwealth of Massachusetts
Department of Industrial Accidents
a
1 Congress Street, Suite 100
Boston, MA 02II4-20I7
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:
Address: U O Anse 1 +4Q [ l +
City/State/Zip: W. r mo ALA-4-in [) '� & "I Phone #: i q b
Are you an employer? Check the appropriate box:
I. to I am a employer with 1%employees (full and/
or part-time).*
2. ❑ 1 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.]
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
H ❑ Health Care
12.EZ Other _TY'5� _hGn ll,,if. MCf'
*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 # oExpiration Date: 25 — I CkU l I
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. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person:
www.mass.gov/dia
Phone #•