HomeMy WebLinkAbout2025-26Ch. r.Jo - at9-?
LICENSE FEE SI50 BHHM-25-39
TOWN OF YARIIOUTH BOARD OF HEALTH
LING AND STORAGE OF TOXIC OR HAZARDOUS M,"\TERIALS
LICENSE APPLICATION
HIS APPLICATION AND RETUruT* IT WITH THE LICENSE FEE
BY JUNE 30. 2025
PLEASECoMPLETEALLOLIESTIONS -,.,t. c a9, Sil:;:.]
NAMEoF BUSTNESS ttAGlCleA'.JOq9 |l,,1'r1J.''y?oJ^,"/d u'rrrirttret.+ *b-764 8oo)
BUSINESS ADDRESSINyARMouTH l3C3 8uc($-l- - Sout.l-axl''ou)U
MArLrNc ADDRpss lJ63 @qr'aSG 5+ - $,+A/Ya^)nod b oa61
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EMAIL ADDRESS /Y] A tcLe h{gL\Cc,
BE]QIJIBED MANAGER/CONTACT PERSON
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nA*" rcLl StL vA TEL,#5d zz-t z5 8+RFOUIRl'D OWNER NAME
HoMEADDRESS 55 9*t}+oL AOe lfy'A-^t,S- lrtc- OZ€o-!-
CORPORATION NAME (IF APPLICABLE)ry1c.a1h o,untt Horrr, a -Ct!iT'e{Z e r e 5 Y }
coRpoRArIoNADDREss fe S B.W - o e 6,6.a
MAILING ADDRc ss lnQ 'C!;cn*\Ca c.cLg 0,-1t"1- (e"'^'
TAx ID (I..EIN oR SSN)REOUIRED q 3+J96 Eiu
Town ofYarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check
appropriately ifpaid: yes V no- nla-
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of anvlicense or permit to operate a business ifa person or company does not have a Certification of Workers Compcnsahon
insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclos€d Workers
Compensation Affidavit. If not applicable, please explain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ONFILE Y N
AIIY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEATT' "*N*#'*,.RENEWALAPPLICATION- NEWAPPLICATION-]I-
rL-APPLICANT'S SIGNATURE:
LICENSES RT'N ANNUALLY FROM JULY I TO JLTNE 30. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLINE 30. FAILURE TO DO SO WILL
RESULT IN CLOSURE OF YOI'R ESTABLISHMENT L,NTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
TO REOPENING.
oln., 1l?f lz5
i__ The Commonwe th of Massuchuselts
- =,= -
Departmenl of Industrial Accidents
. r = lr- -,l-f ._-;,- Ofrice of Investigotions
=*:e - Ldal'ette Cifi'Center1*r.' " 2 Avenue de Ldo),ette, Boston, MA 021I I - 1750
,t " ' www.moss,gov,/clia
Workers' Compensation Insurance Affidavit: General Businesses
Please Print Legiblv
Businessi Organization Nu..,Vl0 fiuA Uor4L I'1 Lrrun+ tM]
Address:J363 ERilCA. ? . fotwlq*wd-t '02669'
2.E I am a sole proprietor or partncrship and have no
cmployccs working for mc in any capacity.
, INo uolkcrs comp. insurancc rcquircdl
3. [f we are a corporarion and lls olliccrs harc cxcrcrscd
Are !ou an emplol'er? Check the appropriate bor:
thcir right ofcxcmption pcr c. l5l. \ I (4). and wr- harc
no cmployces. INo workcrs' comp. insuranct'required]*
We are a non-protit organization. staf'tid by voluntccrs.
with no cmployees. [No workcrs' comp. insurancc req.]
l
cmployces ( t'ull antl,l.E I am a employcr with
or part-timc ). *
Crty/State/Zip f A- -C?66q ,fiA phon"#, 56 )61 f6 o 3
Business Typ€ (required):
5. ! Retail
6. ! Rcstaurant,rBar,Eating Establishment
l. [|Onice andror Salcs (incl. real estatc, auto, crc.)
8. ! Non-profit
9. ! Entcrtainment
10.! Manut'acturing
ll.! Health Carc
t2.fl othcr
+ Ally applicant that ch cc ks bor a I m ust also fi ll our lhc soction bclolr showrng thcir \r orkers compensalion policy in fomralion.
''Il rhe corporatc officcrs hr\ e e\cmprcd rhcmscl\'es. bur thc corporalion has olher employccs. a \rorlcrs' compensation poI.! is rcqurrcd alld such an
organization should check box ll.
I unt u enrrktlet thtt is proiding wtrliers' .ontpe roliotr itrsururrL'efor ny enrpktleet. Belor is the politf inlorn ion.
Insurance Company Nu."' 6 L]U S 6
rnsurer'sAddress: P 0,6ot &5p, "
CityrS1,,,",', O
Policy # or Selt'-ins. Lic. #6SGtuO -Arob?-s8-q-zs Expilation Datc zo- z6
Attach a cop! ofthe $'orkers' compensation policl declaration page (sho}ling the policv number and €rpiration date).
Failurc to sccurc corcragc us rcquired under \ l5A ofMGL c. l5l can l!'ad to thc imposition ofcriminal pcnaltics ofa linc up
to S 1.500.00 and,'or onc-year imprisonmcnl. as $ ell as civil pcnalties in thc lbrm of a STOP WORK ORDER and a finc olup to
Sl-i0.00 a da1 against thc riolator. Bc udriscd that a copy ot this statcmcnt may bc firruardcd to thc, Otlicr,'of Invcstigations of
thc DIA tbr insurancc covcragL' r'critication.
I do hereby ce ., uuler lhe pd \ und penuhies of perjrtrl. thd lhe itfirnrulio proyided abore is lrue ond correcl.
D,".: 1 lzq
fono 06laz
at
Phonc +; 5%ZLLzgtt
Do ot write ifi this (reo, kt be contpleled b1,ci4, or town otJiciul.
Permit/License #
Issuing .\uthoritl (check one):
I [Board of Health 2.E) Building Department
5! Selectmen's Office 6. flothcr
Contact Person:
OfJi<iol use onl.1'
Phone #:
3.flCitr rTon n Clerk .1. E l.icensing Board
C itl or l orr n:
\\ !r \\ nrass go\ dr,l
Information and Instructions
Massachusetts General Laws chapter 152 requires all employcrs to providc workcrs' compensation for their cmployecs.
Pursuant to this slatlutc, an emplolee is detined as "...every person in the scrvice ofanother under any contract of hirc,
cxpress or implied, oral or written."
An entploler is detined as "an individual, partnership, association. corporation or other legal entity. or any rwo or molc
ofthe forcgoing cngagcd in ajoinl cntcrprise, ancl including the lcgal reprcscntativcs ofa deccased cmploycr, or thc
rcceivcr or trustee ofan individual, partnership. association or other legal enriry, cmploying employccs. However, the
orvne-r of a dwclling housc having nol morc than threc apartments and who resides therein. or the qccupant ofthe
dwclling housc of anothcr who employs pcrsons to do maintcnancc. construclion or rcpair. work on suih rlu,elling housc
or on the grounds or building appurtenant thercto shall not because of such employment be dcemed to bc an employcr."
MGL chaptcr 152. sr25C(6) also statcs that "every state or local licensing agcnc] shall withhold the issuance or
re]Iewal of a license or permit to operate a business or to construct buildings in the commonwerlth for anv
applicant who has not produced acceptable evidence of compliance with lhe insurance coverage required."
Additionally, MGL chaptcr I 52, \25C( 7 ) states "Neithcr the commonwealth nor any of its polirical subdivisions shall
entcr into any contract for the performance of public work until acceptablc evidcnce ofcompliance with the insurancerequircntcnts ofthis chapter have bc,.-n prcsented to thc contracting authoriry."
Applicants
City or Town Oflicials
Plcasc bc sure that thc nflldavit is complctc and printcd legibly. Thc Dcpartmcnt has provirlcd a space at the bottom
of the atlidavit tbr you lo till out in thc cvcnt thc Ollicc ol lnvcstigations has to contact you rcgarding the applicant.
Plcase bc sure to till in the permit/licensc number which will bc uscd as a rcfcrcnce number. In addition, an applicant that
must submit multiple- pe'rmit/license applications in any givcn ycar, nced only submit one affidavit indicating currentpolicy information (if ncccssary). A copy ofthc aflidavit that has been ofticially stamped or marked by the ciry or roun
may be providcd to thc aPplicant as proofthat a valid aftjdavit is on tile for luture permits or licenses. A new affidavit
must be filled out each year. Where a homc owner or citizen is obtaining a license or permit not related to any busincss
or commercial venture (i.c. a dog liccnse or permit to bum leaves etc.) said pcrson is NoT rccluircd to complete this
atlidavit.
The Depanment's address, telephone and firx number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette,
Boston, MA 021I l-1750
Tel. (857) 321-7406 or l-877-MASSAFE
Fax (617) 727-7749
torm Rerrsed 7 20le www.mass.gOv/dia
The of.fice of lnvestigations would likc to thank you in advance for your cooperation aml should you have any questions.
please do not hesitate to givc us a call.
Plcase fill out the workers' compensation aflidavit completely. by chccking the boxes that apply to your situation and. il'
ncccssary' supply your insurancc company's namc, address and phone number along with a cenificate ofinsurance.
Limitcd Liability Companies (LLC) or Limit(rd Liability Pannerships (LLP) with no employees other than the membcrs
or partners' are not required to caffy workers' compensation insurance. lf an LLC or LLP does have employees, a policy
is rcquired Be advised that this af'tidavit may bc submittetl to the Departmenr of Industrial Accidents fix confirmation ol'
insurance coverage. Also be sure to sign altd date the aflidavit. The affidavit should bc rcturncd to thc ciry or town
thal thc application for thc permit or licensc is bcing rcqucsted, not thc Department oflndustrial Accidents. Should you
have any questions regarding the law or ifyou arc lcquired to obtain a workers' compensation policy. plcase call the
Department at the number listed below. Sclf-insured companies should enter their self-insurance license numbcr on theappropriatc line.