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Home My WebLink About2025-26cnefut'\| L5ffl LICENSE FEE $ I50 BHHM-23- TOWN OF YAR}TOUTH BOARD OF 202512026 HANDLING AND STORAGE OF TOXIC OR LICENSE APPLICATION CONIPLETE THIS APPLICATION AND RETURN IT BY JUNE 30, 2025 HEALTH HAZARDousrle,BErALS wrrHrHE.,r8p.l3 Br,,*a.no.r, PLEASE CONIPLETE AI-I, QLTESTIONS NAMEoFBUSTNESS.rll lSeq:z.vl Hocrft*[ilz t na susrNnssml,* 5b(' jqQ-16oo T o BUSINESS ADDRESS IN YARMOI]TH MAII-ING ADDRESS 9 a EMAIL ADDRESS ts,EQUIBED MANAGER/CONTACT PERSON TELEPHONE# 4)g- 3q Q -1do o R[-OL I RFT) I IOME AI)DRESS OWNERNAME fA\^*r/a.-Fz.if Fc-\J rEL# al'\-1La-(:{q CORPORATION NAME (IF APPLICABLE)Al t sa."r.^^-\ Ho< ,ilo litr t?aTEL. # U I'ORPORATION ADDRESS 9..-;.. .{) oln* MAILING ADDRESS rAx rD (FEIN oR ssN)BE(IUIBED < t - rt6 3 9.tq1 LICENSES RLTN ANNUALLY FROM JULY I TO JUNE 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 YOUR ESTABLISHMENT INTIL 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 liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes_)21 no- n/a_ 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 Compensation Aflidarit. If not applicable, Dlease explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE YN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. T N APPLICANT'S SI(iNATURE NEW APPLICATION DATE:6# RENEWALAPPLrcAIrcN I,/ The Commonwealth of Massachusetts Departm ent of I nd u strial Acc idents OlJi c e of I nv es tig at i o n s Lafayene City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation InsuranceAflidavit: General Businesses Business/Organization Name:c, Address: City/State/Zip: 3 Yanv'azu.tl^. rnA. o-16((Phone#: 9U(- 31t{ -16.n) Are you an employer? Ch€ck the appropriate box: l. EzI am a employer with 1,. (- employees (full and/ l or part-time).r I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exerciscd their right of exemption per c. 152, Sl(4), and we have no employees. [No workers' comp. insurance required]*+ We are a non-profit organizalion. staffed by volunteers. with no employees. [No workers' comp. insurance req.] .l rtlfthe corporate officers have exempted themselves, but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #l- Business Type (required): 5. E Rctail 6. ! Restauranttsar/Eating Establishment 9. ! Entertainment l0.fl Manufacturing I L! Hcalth Care Office and./or Sales (incl. real eslate, auto, etc.) Non-profit 12.[P916.. 7 8 Insurer's Address Policy # or Self-ins. Lic. # 6-3 LbOA L\19o<Ll A 2< Expiration Dare ft.cts.L-lnAA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure covcrage as required undcr $ 25A of MGL c. 152 can lead to the imposition of crimi-ual peualtics ofa frne up to $ 1,500.00 and/or one-year imprisonment, as well as civil penalties in the tbrm 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 stalement may be forwarded to the Office of lnvestigations of thc DIA for insurancc coverage verification. I do hereby cenify, unde the ins and penalties of perjury that the infornrotion provided abote is true and correct. Si tL[e Phone #: S:o<-3.{ q -1{ crD Contact Person: Phone #: Permit/Liccnse # 3E City/Town Clerk 4.ELicensing Board CitY or Tonn: lssuing Authority (check one): lflBoard of Health 2.E Building D€partment 5E Selectmen's Oflice 6. Eother www.mass.govldia Applicant Information Please Print Lesiblv *Any applicant thal chccks box #l musl also fill out the section below showing their workcrs conrpensation policy information. I om an employer that is providing workers' compensttion insurunce for my employees, Below is the policl, inlormation. Insurance company Name: Hae tr-f..,t-\ L7.,^.-(r+ wz.i Fzt 'l-.-r-.-g Cr; Cityistate/Zip: T.-.-* \-"a OtA . 6.91FO OlJiciol use only. Do ,tot write in this area, to be completed by ci1r or town olJicial. 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 ofanother under any contract of hire, express or implied, oral or written." An employer rs defined 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 representatives ola deceased employer. or the recciver or trustee of an individual, partnership, association or other legal cntity, employing employees. Howeyer, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house ofanother 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 employrnent be deemed to be an employer." MGL chapter 152, g25C(6) also states that "every state or local licensing agency shall withhold the issuance or rcncwal of a license or pcrmit to operate a busincss or to construcl buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insuranc€ coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neilher the commonwealth nor any of its political subdivisions shall cntcr into any contract for lhc pcrfbrmance of public work until acccptablc c',idcnce ofcon:pliancs with the insurancc rcquircments of this chaptcr have been prescntcd lo thc contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your sitr,ration and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companics (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Ilan LLC or LLP does have employees. a policy is required. Be advised that this affidavit may be submitted to the Depanment of Industrial Accidents for confirmation of insurancc coverage. Also be sure to sign and date the aflidavit. Thc affidavit should be retumcd to the city or town that the application for the permit or license is being requested. not the Depanment 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 cnter their self-insurance liccnse number on thc appropriatc line. The Office of Investigations would like to thank you in advance 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 Massachusefts Department of Industrial Accidents Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston. MA0211l-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 www.mass.gov/dia City or Town Officials Please be sure that the affidavit is completc and printcd lcgibly. The Department has provided a space at the boftom of the affidavit for you to hll out in the event the Office of Invcstigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiVliccnse applications in any given year, need only submit one afiidavit indicating cunent policy information (if necessary). A copy of the aflidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prool'that a valid affidavit is on hle for future permits or licenses. A new alfidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not relaled to any business or commercial venture (i.e. a dog liccnse or permit to bum leaves etc.) said person is NOT required to complete this affidavit. iHtS CERTTFTCATE tS TSSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON TH CERTIFICATE DOES NOT AFFIRITATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE BELow.THISCERTIFIoATEoFINSURANCEooESNoTCoNSTITUTEAcoNTRAcTBETWEENTHEISSU REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. CERTIF|CATE NUMBER: 11163s4 E CERTIFICATE HOLDER, THIS AFFORDED BY THE POLICIES ING INSURER(S), AUTHORIZED COVERAGES REVISION NU[TBER 05t1212025 lf SUBROGATION lS WAIVED, subject to the telms and conditions of the policy, certain policies may require an endorsemenl. A statemenl on this certificate does not confer rights to the certilicate holder in lieu of such endorsement(s) ADDITIONAL INSURED provisions or be endorsed.IMPORTANT: lf the certillcate holder is an ADDITIONAL INSURED, the policy(ies) must have Devarajulu Reddy AFFOROINC COVERAG€ N(508) 82+8666 dreddy@fbinsure.com 30104TNSURERA HARTFORD UNDERWRITERS INS CO FBINSURE LLC MA O27EO 128 DEAN ST TAUNTON INSURER B INSURER E II{SURED ALL SEASONS HOSPITALITY INC tuA 02664 1199 RTE 28 SOUTH YARMOUTH THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED EELOW HAVE AEEN ISSUEO TO THE INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wlTH RESPECI IO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERI\'IS' EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REOL]CtsD BY PAID CLAIMS INSURED NAMED ABOVE FOR TIIE POLICY PERIOD SEACI-i OCCURRENCE GENERALAGGREGATE S PRODUCTS - COMP/OP AGG lS S OTHER N/ 5E& E.* c COMIIIERC IAL GEN ERAL LIAEILITY clarMs.rraoE I o"au" PERSONAL & ADV INJURY IS seOMBTNEa STNGLE LLMrr BoOILY INJURY (Per p€en)5 s t-,__-.1 I I arros oNLYT---1 HiREo I arfios oNLY BOoIIY INJURY (Ps rcarren0 AIJIOiIOBILE LIAAILiTY SCHEOULEOAIJIOS NON.OWNEO AI]TOS ONLY sN/A ION S EACH OCCI.]RRENCE EXCESS LIAB oEc 03t22t2025 03t2z2a266S60UB 1 K20561425 N/A l,.^1"] EXT Ts I E L OISEASE. POLICY LIMIT 5 500.0000 5 500.000E L, EACH ACCIOENT EL DtsEAsE-EA EMpLoyEgi 5 500,000 WORIGRS COIIENSATIONA O EMPIOYERS' LIABILTTY ANYPROPRIEiOfu PARTNEFYEXECI]TIVE OFFICER,MEMBEREXCLUDEO' DEScRrpTlOr{ OF opERAiIO S / LOCAior{s / VEHTCLES (aCORO lQJ,_addirion.l R.n.rh. S.h.dur., m.y b. ad.ch.d ir mor. spae is r.quiEd) Workers' Compensation benefits will be paid to lvlassachusetts employees only. Pursuant to Endorsement WC 20 03 06 B. no authorizahon is gven to pay claims for beneflts to employees in atates other than Massachusetts if the insured hires or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was rssued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The slatus of this coverage can be monitored daily by accessing the Prool of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION All Seasons Hospilality, lnc. 1199 Route 28 MA 02664 AUTHOR12ED REPRESENTATIVE Daniel M. Croidly, CPCU, Vice President - Residuat Ma*el - t /CRtBMA O 1988-2015ACORD CORPORATION. AIt rights reserved The ACORD name and Iogo are registered marks of ACORDACORD 25 (2016/03) ACORD_P CERTIFICATE OF LIABILITY INSURANCE L s N/A S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES AE CANCELLED BEFORETHE EXPIRATION OATE THEREOF. NOTICE WILL AE DELIVERED IN ACCORDANCE WTH THE POLICY PROVISIONS. South Yarmoulh