HomeMy WebLinkAbout2025-26ch No tz)d-b
JUNE 30. 2025
PLEASE COMPLETE ALL QUESTIONS
NAME OF BUSINESS Arclen Bv Bes/ wesl.rn
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LICENSE
FEE: $ 150.00
TOWN OF YARMOUTH BOAR-D OF HEALTH
2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS
LICENSE APPLICATION
PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY
S,SH;I3
BUSINESS TEL. #{"8.778. ttoo
BUSTNESS ADDRESS rN yARMourg "17( n ci^P wtes*Tnootlr
MAILTNG ADDRESS Ll7( he ths f u:el Ya.?iqoo{.rt14 o 24"1
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EMAIL ADDRESS 6n @li/en Ycrrr,oolA.
REQT'IRED MANA GEPJCONTACT PERSON pSATH (mA pA6E A)
TELEPHoNE# 2o3, /8?. t92q
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CORPORATION NAME (IF APPLICABLE)rt 9 a.tt
CORPORATTON ADDRESS llotr
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MAILING ADDRESS A zQ
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LICENSES RUN ANNUALLY FROM JULY I TO JIJNE 30. IT IS YOUR RESPONSIBILITY To REI.URNTHE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILLRESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIORTO REOPENING.
Town of
appropria
Please chcck
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of an
Yarmouth taxes and liens must be paid prior to renewal or issuance of you, p..-its
tely if paid: yesTa no_ n/a_
vlicense or permit to operate a business ifa person or company does not have a Cenification of Workers Compcnsatlon
insurance. As part ofrenewal or issuance ofyour permits, you must complete the enclosed workers CompcnsationAIIidarit. Ifnot applicablc, please explain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SA.FETY DATA SHEETS ON FILE
YN
ANY NEW CHEMICALS MUST BE PR-E.APPROYED BY THf, HEAI,TH DEPARTMENT.
RENEWAL APPLICATION NEW APPLICATION
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APPLICANT'S SIGNATURE
DATIl 4 /g, /znzs
REOLIIRED OWNER NAME rEL.# ]g/.gsl.g?o(
TAX ID (FEIN OR SSN) REQUIRED
A,C@RI)CERTIFICATE OF LIABILITY INSURANCE DATE (MIIUDOI/YYY)
9t4t2025
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERJIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTENO OR ALTER THE COVERAGE AFFOROED BYTHE POLICIES
BELOW. TH|S CERTTFTCATE OF TNSURANCE OOES NOT CONSTTTUTE A CONTRACT SETWEEN THE TSSUING INSURER(S), AUTHORIZEO
REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLOER.
TMPORTANT: lf the cerlificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisaons or be endotsed.
It SUBROGATION lS WAIVEO, subiect to the terms and conditions ofthe policy, certain policies may require an endorsement. A statemeol on
this certificate does not confer ri hts to the certificate holde. ir lieu ot such erdorseme s
PROOUCER
Bouttord lnsurance
157 S River Rd. Unit
Bedford, NH 03110
l8ency
fi8ilI4cr Francis Ouispe
fJ8lfi. en), (603) s73-7228 i#
iiHtEss f rancis@boufford ins.com
tNsuRER{S) AFFORDTNC COVERAGE
rNsuRER a :Technology lnsurance ComPany
xo),(603) 67!-7?9q
- NAIC I
12376
IIISURED INSURER B
INSURER C
INSURER O
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED ]O THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INOICATED, NOTWITHSTANDING ANY REOU1REMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WHICH IHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN IS SUEJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUC€D BY PAID CLAiMS.
LrlrllTsTYPE OF INSURANCE
GEN'L AGGREGATE IIMIT APPLIES PER
PoLrcY ?Ag Loc
COMiIERCIAL GENERAL LIABILITY
CLAIMS-|V1AOE OCCITR ;
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!
ot
AUTOIVTOAILE LIAEILITY
OWNEDAUTOS ONLY
SCHEDU!EDAUTOS
NON-OWNEDAUIOS ONLYHIREOAUTOS ONLY
UMBRELLA LIAB
EXCESS UAB
OCCUR
CTAIMSMADE
: COMBINED SINGLE LIMIT+-.u
fq0!uru!8!ft*!4+
I BOOILY INJURY lPer adl@fl): S
PROPERTY DAMAGE
-ee.6@iscL
-
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SIAIUTE OTH
ER
DED RETENTION$
A woaxeascoupetsa-nottANO EMPLOYERS' LIABILITY
A'!Y PROPR]ETOR;PARTNER/EXECUTIVE
OFFICER]MEMBER EXCLUOEO]tir.ndatorv rn NHI
I yes de$nbe under
DFSCRIPTLON OF OPFRAT ONS beo*
TWC4670828 1,000,000
1,000,000
1,000,000
E,L EACH ACCIDENT
. E,L. DISEASE. EA EMPLOYEE S
Lll'i
CE TIFICA o CANCELLA
AUT]IORIZEO REPRESENTA'ITVE
SHOULO ANY OF THE AAOVE DESCRIBED POLICIES BE CANCELLEO BEFORETHE EXPIRATION DAIE THEREOF, NOTICE WILL BE OELIVEREO ItI
ACCOROANCE wlTH THE POLICY PROVISIONS,
o 1988-2015 ACORD CORPORATTON
The ACORD name and logo are registered marks ot ACORD
ACORO 25 (2016/03)All rights reserved
JAMSHOT.O,I
s&H Hotel Yarmouth LLC
Jamsan Hotel Management lnc.
110 HartwellAve Suite 300
Lexington, MA 02421
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DAMAGE TO RENTED:!A@ISES IEaelslqclEL
-!Eo EXIlAry oi6 !g!en)
PERSONAI & AOV INJURY
:G-ENER&!GGREGATE
PRODUCIS . COMPDP A6G
] EACH OCCURRENCE
: AGGREGATE
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s
8t1t2025 8r1t2026
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OESCRlPnoN OF OPERAIIOIIS / LOCAIIOIIS / VEHICIES (ACORO l0l, Addilional Rema r srh.duL. may b. attachHl il mol. spac. is..quircd)reference location: 476 MA-28 Wesl Yarmouth. MA
Town of Yarmouth
1146 Route 28
South Yarmouth, MA 02664
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