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Home My WebLink About2025-26,o c, LICENSE FEE $I50 TOWN OF YARMOUTH BOARD OF HEALTH 2025/2026 HANDLING .{,ND STORAGE OF TOXIC OR HAZARDOUS I\,IATERIALS LICENSE APPLICATION CONIPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY .'UNE 30. 2025 crc+ toE3 s-Ea \ 9S DPLEASE CONIP ALL OUESTIONS NAME OF Bt]SINESS 14 BUSINESS ADDRESS IN YARMOUTH 3t MAILINGADDRESS 1- <ornn /j--< Alrtv<- I2 t fllllt. B(]SINESS TEI- * NO Ll EMAIL ADDRESS REOUIRED MANAGER/CONTACT PERSON €,-2_ TELEPHONE I oB.ulllBEI)owNER NAME HOME ADDRESS CORTORATION NAME (IF APPLICABLE G b"qd- baz TEL.#q a o 4 TEL. #-q -----)CORPORATIONA"*U'5 4_.w){ MAILING ADDRFSS <-As €_ o -oSoO66 LICENSES RLIN ANNUALLY FROM ruLY I TO JL]NE 30, IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLINE ]0, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT TINTIL 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 raxes and liJxls must be appropriatell ifpaid: yesyl no paid prior to renewal or issuance ofyour permits. Please check a Under Chapter 152, Sec. 25C, subsection 6, the Town of yarmouth is required to hold issuance or renewal ofanylicense or permit to operate a business ifa person or company does not have a Certification of Workers Compensationinsurance. As part ofthe renewal or issuance ofyour permits,you must complete the enclosed WorkersCompensation Affidavit Ifnot applicable, please cxplain H I D 5 REGISTRA TION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE ANY NEW CHEMICALS MUST BE YNRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION NEW APPL /'Z N APPLICANT'S SIGNATURE ATION DATE --------2 TAx ID (FEIN OR SSN) REOI.JIRF-D 4P{ The Commonweolth of Massachusetts Departm e nt of I ndustrial A ccidents Ofji ce of I nv es ti g atio n s Lafayette City Center 2 Avenue de Lafoyette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant lnformation Please Print Legiblv Business/Organization Name:br I z e) Address CitylState/Zip:U+l^Yw0266 non"*, (\08)3qq-4ooo Business Type (required): 5. ! Rctail 6. I Restaurant,'Bar/Eating Establishnent 7. 8. 9. l0 Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing I L l-l He alth Carc n-drner *lt lC/- *Any applicant that checks box #l must also fill out the section below showing their workers compensation policy information. +.Ifthe corporate officers have erempted themselves. but the coaporation has other employees. a workers' compensalion policy is required and such an organization should check box #1. 2 3 4 th Vct LlU emptoyees (tull and/ or part-time).* I am a sole proprietor or partnership and have no employees working for me in any capaciry. [No workers' comp. insurance requiredl We are a corporation and its officers have exercised their right of exemption per c. 152, S I (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.] Are yqri an employer? C t.B'Iu a employer wi eck the.appropriatr bor: I om an empktyer thal is providing workers' compensation tnsurs ce for my Insurance Company Name Ciry/State/Zip s,Below is the po nformation Expiration Date declaration page (showing the policy numbrr xpiration date) Policy # or Self-ins. Lic. # Attach a copy of the wor Failure to secrue coverage kers' compensation as requircd undcr $ ti n e 25A of MGL c. 152 can lead to the irnposition of criminal penalties ofa lure upto$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 upto $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office oflnvesti gations of P the DIA for insurance covcrage catror) I do hereby certifu, und,rh qnd Si ce Ities ofperjury that the inlormotion provided abore is true and correct. Date 2a- OlJiciol use only. Do not b,rite in this area, to be completed by city or town official. lssuing Authority (check one): I EBoard of Health 2.EI Buildingsfl Selectmen's Oflice 6. Elother Contact Person: Departm€nt 3^E Ciry/Town Cterk 4.ILicensing Board Permit/License # Phone #: www.mass.gov/dia Insurer's Address: Citv or Town: Information and Instructions MGL chapter 152, $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 business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for thc performance of public work until acceptablc evidence of compliancc with the insurance requirements of this chapter have bcen prescntcd 1o the contracting authority." Applicants Please lill out the workers' compensation amdavit 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 Limited Liability Partnerships (LLP) with no employees other than the members 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 Industrial Accidents for confirmation of insurance coveragc. Also be sure to sign and date the amdavit. The affidavit should be returncd to the city or lown 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 if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Sclf-insured companies should enter their self-insurance license number on thc appropriate line. City or Town Officials Please bc sure that the affidavit is complcte and pnntcd legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. ln addition, an applicant that must submit multiple permiVlicense applications in any given year, need only submit one affidavit indicating current 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 proofthat a vaiid allidavit is on irle for future pernits or licenses. A new afhdavit 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 licensc or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The O{fice of Invcstigations 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 rhe Department's address' telephone Tfl3l:H*:r*ealth of Massachusetts Departrnent of Industrial Accidents Office of Investigations Lafayette CitY Center 2 Avenue de LafaYette, Boston, MA02ll1-1750 Tel. (857) 321-'r-406 or 1-877-MASSAFE Fax (617) 727"1749 Form Revised 7,'2019 wWW'maSS'gOV/dia Massachusetts General Laws chapter 152 requires all employcrs to providc workers' compensation for their employees. Pursuant to this slatu,le, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership. association, corporation or other legal entity, or any fwo or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustce ofan individual, partnership. associalion or other lcgal entity, employing employees. Howcver, the owner ofa dwelling house having nol more than three apartments and who resides therein. or the occupant of the dwelling house ofanother who employs persons to do maintenance. construclion or repair work on such dwelling house or on thc grounds or building appurtenanl thereto shall not because of such employment be deemed to be an employcr." Techndogy lnsuance Company, lnc. A $od( harmc. OonTary WORKERS COMPENSATION ANO EMPLOYERS LAAILIry INSURANCE POLICY wc990001 B 10f 5 INFORMATION PAGE Ncci Co&: 39071 Insured: Cayatri (rupa Corporarion DBA:.Arnbsssador Inn & Suites l3l4 RGrte 28 South Yarmouh, MA 02664 Other workplces not shown above: None Prodscer: The Baldwin Croup SoutEast LLC 410 University Ave westwood, MA 02090-231 I Policy Numbor:'fWC4572735 _lndividual X Corporalion kderal Tax ID: Rist ld: Renewal ol Pannership 2fx)55fi)66 TWC4395612 2. The policy period is ftclrrl.3l9/N25 to 31912U26 I ?:01 a"m. at the insured's mailiog address' 3. A.wort€rs Compensation Insuranct: Pan One of tlrc policy applies to dle wortels Compensation [aw of th€ $ares listtd here; Massschusetls Employers Liability Insurance: Parl Two of the policy applies to wort in each stae listed in item 3.A. The limib of our liability ond.r Pan Two Ite: Stste Bodily Injury by Accid.nt Bodily Injury by Disease Bodily Injury by Discas€ 3500,00 each accident $500,000 policy limit $500,000 each employee other Sues lnsurance: Pafi Three of ahe policy oppli€s to thc stares, if any, listed here: All slates exc€!,r ND, OlI, WA, WY ard Ststds) Designabd in Item 3.A B c. D.This policy includes these eodorsemenu and scHules: See Extension of Informarion Page 4 The premium for this policy will be detcrmiaed by our Manuals of Ruks, Classifications. Rat€s ad Raring Pl8na. All inforrration rcquired below is subj€ct to verification and chan8p by audit. See Ext€nsion of Informarion Page TOTAL ESTIMATED AIINUAL PREMIUM STATE ASSESSMENT TOTAL ESTIMATED COST Minimum Premium Deposit Premium Issue Da!e: Zll2025 Countersigned by: 2335 87 2322 196 1lt1 Repres€ntative ta: E N Ii ffi ,g