HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee
Town of Yarmouth Waived
Food Establishment License
Number: BOHF-15-1845-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
DENNIS-YARMOUTH REGIONAL SCHOOL DISTRICT 276 STATION AVE
STATION AVENUE ELEMENTARY SCHOOL SOUTH YARMOUTH, MA 02664
276 STATION AVENUE
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A LICENSE
TO OPERATE:
Non-Profit
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
(2, 4
Bruce G. Murph , MPH,R.S., CHO
Health Director
The Commonwealth of Massachusetts
Department of Industrial Accidents
�-- Office ofInvestigations
1 1 Congress Street, Suite 100
='0�•yi3= Boston, M4 02114-2017
w' ♦ 1.
www.mass.govldia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/OrganizationName: ' Eti'/ils �i 4“7.11 4,,A:,/•445C/147a- CDs 7)2/C--
Address: Y S i7oEfi
City/State/Zip: `Ai)I (�,9femda..rf ✓4' Phone #: 5Z0-- ?Qi'--7loo •
Are you an employer? Check the appropriate box: Business Type(required):
I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.0 1 am a sole proprietor or partnership and have no i �-
I I 7. 1. Office and/or Sales(incl real estate,auto,
e ars:�y' es.,vorking or silo.in any capaUty. etc.)
[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.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other L Due
*Any applicant that checks box#t 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: Es-1,c,7-2w0ti StZt//c(
Insurer's Address: PO COX A
•
City/State/Zip: /14 4,16„ 4) 4) /Vi 36,V
Policy#or Self-ins. Lic. # ECt/c-666,61 (/ Expiration Date: ta(3t/ ,,2,z
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, ; •r the pail ndpenalties of perjury that the information provided above is true and correct.
Signature: c>u '" Date: /2776// /
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.gov/dia
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