The URL can be used to link to this page

Home My WebLink About2025-26L\C $tqs+-bl-l#N-a:- lragLICI]NSE FEt] S I50 TOWN OF YAR}IOUTH BOARD OF HEAI,TH 202512026 HAI'.IDLING AND STORAGE OF TOXIC OR HAZAR.DOUS MATERIALS LICENSE APPLICATION CO]IIPLETE THIS APPLICATION AND RETURN IT WITH THE BY JUNE 30, 2025 PLEASE COMPLETE ALL OT'ESTIONS NAME oF BUSTNESS yi O C w ay !ft.ef*rR BUSINESS TEL, # BUSTNESS ADDRESS rN yARMoUTrr .?+I u)L+ tfl:,1 pn f/t .gt,l,l&ua.t ,ff, MAILING ADDRESS .i,4u.e ,,-,ll, PT, leLvl \t 9r{lll5 DsEMAIL ADDRESS RFOUIRET)MANAGER/coN r ecr pzpsox Afi *flEE HIU// n/ TELEPHoNE# 14iltr B[oIJIB[DowNnnNarrae SA&IE rEI-.+ HOMEADDRESS l ht^6 CORPORATION NAME (IF APPLICABLE)-TEL. # CORPORATION ADDRESS MAILING ADDRESS rAx lD (FEIN on ssrrBE{E_IBED LICENSES RUN ANNUALLY FROM JULY I TO JTNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY JUNE 30. FAILI,IRE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT LNTIL 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 [iens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yesj no - nla- 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 ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compe nsation Aflidavit. If not licablc, plcase explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED YN ALL SAFETY DATA SHEETS ON FILE N ANYNEwCHEMICALSMUST.BEPRE.APPRoVEDBYTImIIEALTHDEPARTMENT. RENEWAL O,,,-,.O,,O* '/ NEW APPLICATION- APPLICANT'S SIGNATTIRE , ,2 DATE ,'UN r ti 2025 t /tt /*s The Commonwealth of Massachusetts D epartm e nt of In du strial Acc ide n ts Olfice of I nvesti g ation s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses Business/Organization Name o /ar;,5 R Address: 741 lztlht'le's pa*/-t 3 --7qr.orc.orq O){4+ City / State I Zip | _ Phone # :1 -74-t3L-7zt; Are you an employer? Check the appropriatc box: l.! I am a employer with employees (full and/ .cr pan-time).* 2.V I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right of exemption pcr c. 152. S I (4). and we have no employees. [No workers' comp. insurance required]* +. ! We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ! Retail 6. E Restauant,/Bar/Eating Establishment 7. 8. 9. l0 Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing I L! Hcalth Care l2.E orher *Any applicant that checks box #l musl also fill out the section below showing their workers' compensalion Policy information. **lf the iorporate officers have exempted themselves, but the corporaiion has other employees. a workers' compensation policy is requited and such an organization should check box #l I am an employer that is providing workers' compensalion insurunce fot my employees. Below is lhe policy information- Insurance Company Name:- Insurer's Address: Policy # or Self-ins. Lic. #Expiration Date Attach a cop)' of thc worker s' compensation policJ- declaration page (showing the policy number and €xpiration date)' Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa finc up to $1,500.00 and/o, on"-y"u, imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a ltne of up to $250.00 a day against thi violator. Be advised that a copyofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veriitcation. I do hereby ceaify, under the Po l s atl Si etttlties of perjury that the inlormation provided above is true ond correcl. Datc G-t+zr Phone # Official use only. Do not wite in this drea, to be completed by ci4' or town official' 5[ Selectmen's OIfice 6. Eother Permit/License # Phonc #: 3.E City/Town Clerk 4.flLicensing Board Contact Person: City or Town: lssuing Authority (check one): I lBoard of Health 2.E Building Departm€nt www.mass.gov/dia Applicant Information Please Print Lesiblv H City/State/zip: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statule, an employee is defined as "...every person in the service of another under any conlract of hire. express or implied, oral or written." An employer is detined as "an individual, partnership. association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enterprise, and including the legal representatiyes ofa deceased employer, or the receiver or trustee ofan individual, partnership, association or other lcgal entity, employing employees. However, the owner ola dwelling house having nol more than three apartments and who resides therein, or the occupant ofthe dwelling house ofanother who employs persons to do maintenance. construction or repair work on such dwelling house or on thc grounds or buildrng appurtenant thereto shall not becausc of such employment be deemed to be an employer." MGL chapter 152, $25C(6) also slates that "every state or local licensing agency shall withhold the issuance or rencwal of a license or permit to operatc a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Addilionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidcnce ofcompliance with lhe insurance requircmcnts of this chaptcr havc bccn prescntcd to thc contractxrg authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate ofinsurance. Limited Liability Companies (LLC) or Limitcd Liability Pa(nerships (LLP) with no employces other than the membcrs or partners, are not required to carry workers' compensation insurance. Ifan LLC or LLP does have employees. a policy is required. Be advised that this affidavit may be submitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidrvit. Thc affidavit should be retumed to the city or tow,ll that the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed bclow. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Olficials Please be sure that the affidavit is complctc and printed lcgibly. Thc Dcpartment has providcd a space at the bottom of the alfidavit for you to fill out in the evcnt the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any givcn year, need only submit one affidavit indicating current policy information (if necessary). A copy of the alfidavit that has been officially stamped or marked by the city or to\41 may be provided to the applicant as prool'that a valid affidavir is uu filc lor fuiutc pcrmits or licenscs. A new afiidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT rcquired to complete this affidavit. The OIfice of Investigations would like to thank you in advancc for your cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA021ll_1750 Tel. (857) 321-'7406 or t-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia