No preview available
HomeMy WebLinkAboutApplication and WC Ino-oo1/5 64-sT'-/q RECEIVED Acir NI TOWN OF YARMOUTH {� 9 4 2020 trzn. 1146.ROUTESOUTH YARMOUTH, HEALTH DEPT. 28, UTt�N1AssACH[rs��is a266a-24451 Telephone(508)398-2231,ext.1241 Board of H : F''`. Fax(508)760-3472 - A P1 J Health , .:-,f',d�.. Division .4w. &� . . ... i((9CIA SUN TANNING ESTABLISHMENTS APPLICATION FOXLICENSFlpFRMIT-2020 ufellfic55 Name ofEstablishm I Tax ID(FEIN or SSN): _ Address:sw1,43 Wh.lie,45. Path Suite, -D 500bel yorm D 00/2 S08 -391-qqq7 copt_ c_oci. 14Lryi .e.,@„yria,tiCiyil Telephone No.: E-mail: Mailing Address(If different from above): ql Owner/Corporation Name: 4�rrl 1 1 Tel Telephone No.:C /.0 3 I 1 Lli' r�aide- �j c c • Owner/Corporation Address-42 8. U /G l e 3 (. Way calf De /'I i iiCao Manager's Name: Telephone No Manager's A,,*, Under Chapter 152,Sec.25C,subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a certificate of Worker's Compensation Insurance. The attached State Worker's Compensation Insurance Affidavit must be completed and signed. Town of Yarmouth taxes and liens must Jae paid prior to renewal or issuance of your permits. Please check appropriately if paid:yes V no LICENSEIPERMIT REOUIRED: Fee: $55.00 per device #OF TANNING BEDS: #OF OTHER TANNING DEVif FS TOTAL TANNING DEVICE INFORMATION: *.R I. 3 1s0D5 411.4 Manufacturer Model Number Serial Number Type of Bulb gocyaL soq _38/0A 350611 uJo L1. deo R41 ki ko j aLsvn 38 /0A 55.0079 ,AIoL 4 I1 ,D g4. VV.) USG 6 ---65-a--1-512-q -50/Q- &5009 3 fo L —,w le Ro al 601 5o 45o09a ufo(fl. Jtao ,'(' Notice: PERMITS RUN ANNUALLY from January 1 to December 31. It is your responsibility to return the completed application(s)and required fee(s)by December 31. Failure to do so will result in closure of your establishment until the required application(s)and fee(s)are received. A hearing before the Board of Health may be required prior to reopening. DATE: I/023/ao SIGNATURE: -76A/LAD II10520I9 { { T The Commonwealth of Massachusetts I Farm - *.: Department of Industrial Accidents 11=.�liii!_= � Office of Investigations ' � !` �' 1 Congress Street,Suite 100 ",'- Boston,MA 02114-2017 '� = www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 15 Land Tag4- dal') GS'S h I ,,� Pci(9%5 (AJ 1.t L f ci U') 50 s LL I) I Qdioto City/State/Zip:50( yQ r fl7 o U ) a Phone#: u L508 -3 VI L/L/7 Ar!yqu an employer?Check the appropriate box: Business Type(required): 1.IV I am a employer with employees(full and/ 5. [Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance required]** 4.ElWe are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers'comp.insurance req.] 12.["Other Tannin ` *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy-. . ;on. **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: ! me L�da 'i- Cc ( 017 Inst/raVi(&.. Insurer's Address: --P,0• -80 J(, 719 City/State/Zip: 5QriciW t th , nijoi 0.: ,510 5 Policy#or Self-ins.Lic.# V WC—' ioo - pop(Ll0 a; _ao`lk Xpiration Date: 5l`7 L30:310Attach a copy of the workers'compensation policy declaration showin the li number diad ation page(showing policy exp 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 ce ' ,under the pains nd penalties of perjury that the information provided above is true and correct. Signature: Date: 1/423/a 6 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: Phone#: www.mass.govrdia A.i.M.Mutual Insurance Com n Massachusetts Employers Insurance Company Insurance Companiesy New Hampshire Employers Insurance Company Associated Employers Insurance Company since 1989 05/21/2019 KERRIE KIRBY. ISLAND TAN&WELLNESS 23 WHITES PATH SUITE D SOUTH YARMOUTH, MA 02664 ,,b r.j' of cJ COMP. JnsOra n`e_ Re: Workers Compensation Insurance Policy Number. VWC-100-6024022 2019A Policy Period: 05/17!2019 to 05/17/2020 Dear. KERRIE KIRBY Welcome to the AIM.Mutual Insurance Company. Your workers compensation policy with us is currently being processed,and your policy number is noted above. I am a member of the customer service team assigned to your policy. If you have any questions or requests, please feel free to call or email me. If you prefer, you may contact any of these areas directly. Certificates of Insurance Fax:781-270-5690 - Email:certificateregeust aimmutuat.c om Phone: 781-270-8740 or 781-270-8935 Premium Receivable Department Dawn Hurley: (781)270-8724 Richard Federico,Supervisor. 781-221-8638 Claim Online: www.aimmutual.com Phone: 866-270-3354 Fax: 781-270-5599 We took forward te-being of ser-vice to you. - -- Sincerely, 71. e;e4to cur Arian Yin (781)221-8618 ayin@aimmutual.com cc: Almeida&Carlsson Insurance Agency PO Box 719 Sandwich,MA 02563 54 Third Avenue•P.O.Box 4070•Burlington,MA 01803-0970•Tel:781.2211600/800.876.2765•Fax:781.270.5599 CONNECTICUT • MAINE • MASSACHUSETTS • NEW HAMPSHIRE • VERMONT sponsored by Associated industries of Massachusetts