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Home My WebLink About2025-26Ch.No. Llq(!L1b ircsxse F'EE $rso gtlllt l- 23-n H TO\!'\ OF YARNIOUTH BOARD OF HEALTH 2025/2026 HA}iDLIIiC .\ND STORAGE OF TOXIC OR HAZARDOUS M.{TERIALS LICENSE APPLICATION CO}IPLETE THIS APPLICATION AND RETURN IT WITH THE LI BY JUNE 30, 2025 NAME OF BUSINESS 0'U INESS TEL, # BUSINESS ADDRESS IN YARMOUTH ft,5 fr) NlAII-ING ADDRESS Qa hx trzl .S,*nnir \aa U t) P 4t,?fr?.tr tTH DEPT tr EMAIL ADDRESS &tliLillllr MANAGER/CoNTACT PERSoN TELEpHoNE# -.l-.l+ ,,1), q540 ,LCt fr1 D,.lltL t{t_()t Itu.t) owNER NAME Sosn "r t,,E TEL.# HoME ADDRESS t(z Hau.,V r L r t Rr; i,u \ti i- Q Niei Enu 5N ofiqqztl.t f)OTEL. #CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS MAILING ADDRESS Po 6or rrzr;l .S Drtnit rn, O)aU0 TAx ID (FEIN OR SSN)BEIEIBED 0q - }t 84\.,00 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JIINE 30, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RXCEIVED. 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 or issuance ofyour permits. Please check appropriately ifpaid: yes_ no_ nla- Under Chapter 152, Sec. 25C. subsection 6. the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affidavit. lf not applicable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CIIECK AND WORKERS COMP AFFIDAVIT ENCLOSED AT,L SAF-L,TY DATA SHEETS ON FILE { Yx Y N N ANY NEW CHEMICALS MUST BE PRE.,{PPROVED BY THE HEALTH DEPARTMENT. RENEwAL appltcertoN I NEW AeeLICATIoN_ APPLICANT'S SIGNATURE PLEASE COMPLETE ALL QUESTIONS 4u ,)I oerc, dUb5 The Commonwealth of Massachusetts D epa rtment of I n dustrial A ccidents Oftice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses & Aonlicant Information Please Print Lesiblv Business/Organ izationName: Ol,,tJr\O Inc Nf Mun,, ol ftAYLOrl tu ,.5 Dzrrirri 1111 0lbfia Phone #ryY bS64hht yfio J--J Address: CitylSrarclZip Are ,vou an employer? Che t.M I am a employer with or part-time). x ck the appr 1 opriate box: employees (full and/ 2. E I am a sole proprietor or partnership and have no 3 4 employees working for me in any capacity. INo workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4), and we have no employees. [No workers' comp. insurance required]x* We are a non-profit organization, staffed by voluntecrs, with no employees. [No workers' comp. insurance rcq.] Busineps Type (required) 5 Pf'Retarl 6. 7. 8. 9. l0 ll t2 Restaurant/Bar/Eating Establishment Office and./or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care Other tAny applicant that checks box #l must also fill out the section below showing their workers' compensation policy inlormation. '*If the corporate officers have exempted themselves. but the corporation has other employees. a workers compensation policy is required andsuch an organization should check box #l. roviding workers' compe nsatio insuronce lor my employees. Bekw is lhe policy informationI am an employet lhal is p Insurance Company Name lnsurer's Address I 7\b \unt CottryaLJi x City/StatelZip l/t,011 0 # or Serr-ins. Li". # 0t90 06 A44tstfi.a \ )\"Policy Expiration Date Attach I copy of the workers' compensation policy declaration page (showing the policy number and expiration dat€). Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa 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 adr,ised that a copy of this statement maybe forwarded tothe Office of Investigations of the DIA for insurance coverage vcrification. I do hereby certify,the poins utrd alties of perjury thut the infbrmation provided above is true and correct Date tu e Phone # Ollicial use onll', Do not write in this areq lo be completed by ci1' or town olfrcidl. Issuing Authority (check one): lflBoard of Health 2.! Building Department 3.ECity/Town Clerk Permit/License # .1. E Licensing Board Phone #: Citv or Ton'n: 5[ Selectmen's office 6. [Other Contact Person: www.mass.gov/dia t1 Information and Instructions Massachusctts General Laws chaptcr 152 requircs all employcrs to'provide workers' compcnsation for their employees Pursuant to this sta le. at employee is defined as "...every person ir the sewice ofanother under any contract ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee ofan individual, partnership, association or other legal cntity, employing employees. However, the owner of a dwelling house having not more than three apanments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such cmployment be deemed to be an employer." MGL chapter I 52, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a busin€ss or to construct buildings in the commonwcalth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter I52. S25C(7) states "Neither thc commonwealth nor any ol'its political subdivisions shall enter into any coatract for the pcrlbrrnance of public rvork until acceptablc cvidence of compliance with thc insurancc requircnrcnts of this chapter havc been presentcd to the contracting authority." Applicants Please fill out tle 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. Limitcd Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. lf an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted lo the Depanment of [ndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the aflidavit. The afldavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial 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 below. Self-insured companies should enter their self-insurance license number on the appropriatc line. City or Town Officials Please be sure that thc afldavit is complete and printed lcgibly. The Department has provided a space at the bottom ofthe affidavit for you to hll out in the event thc OIfice 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 given year, need only submit one affidavit indicating currcnt policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prool that a valid aflidavit rs on file lbr future permits or licenses. A new alldavit 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 liccnse or permit to bum leavcs etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thant 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, MA02lll-1750 Tel. (857) 321-7406 or 1-877-MASSAIE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia ESTIMATEO BILLING MA Retail Merchants WC Group !nc- PO B,ox859222-9222 Braintree, MA 02185 For Period: January 0'1, 2025 to January 01, 2026 Agway of Cape Cod P Wiles lnc. P.O. Box 1129 South Dennis, MA 02660 hicy Reiercnoe: Division: Print Date: 014005035151125 00000 December 05. 2024 Rating State: MA Class Ext Code 7380 I010 I810 Drivers, chauffeurs 6 Their He { t/o1/202s - 1/o1/20261 store: Hardr.ale I 1/Ot/202s - 1/01/20261clerical office Ernployees Noc I 1/01/2025 - L/01/2026) 3,224 22,094 500 4 .96 -94 .04 Yorr er-t rI b. rrbm.fc{t' dbdAgen!: Arthur J. Gattagher Risk tanag01042 Arthur J. Gal_tagher Risk Manaqemenr Serv233 ilest Central StreetNalick, t{A 01150 (s08 ) 650-8S90 EqElieoce lrJdifieis: lrod ARAP Eff Dates 1- 2900 1.2500 0r/or/2o25 1-2900 25, a14 -O0 1,807 - 00- 240-00+ 24,247 -OO 31,279 -OO 31,2?S.00 1,936.00- 1,820.00+ 37, 163 - 00 1.1O0.0O+ 34,263 -OO 7.00t r.000s 6.19t 1.2500 i. 750000t 38,846.00 Balanco DIA AssessDert ExpeDse Constaflt Preaiun Paid 38,263-00 583-00 Due January 1, 2025 Due Eebruary l, 2025 Due March 1, 2025 Due April 1. 2025 10,148-0O 4,?83-00 4, ?83 - 00 4.783-00 Due !.lay 1, 2025 Due June 1, 2025 Due JuIy 1, 2025 ir,783-00 4,783-00 4. 783 - 00 Anount Due &nuary 1,2025 $10,148.00 Serviced by: Cove Risk Services, LIC Po 8or 859222-9222Braintree, UA 02185(800) 790-887? Page I of I G*o\ 55,000.00 2,3s0,000.00 1,250,000.00 Prsmium ErBaldornMa.ual PreDim Rate DeviationInc Limits: 500/500/500strbject Preniln Experience uodifier Standard PreRiuftt volurne Discount AtrAP Charge Nolma] Plemiu]n Expense constant Domestic Terrori,sll Estlnated Pr€Diu[