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Home My WebLink About2025-26t ? 6.1e r33ct3 filEGtr[ JUt 0 7 ?025 HEALTH OEPT, LTCENSE FEE sr5o nttt/rl- U -t qoq 1'O\1\ OF \"{RIIOT 'I'H BOARD OF HE,\I-I'H 202512026 HANDLING .{ND STORACE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30. 2025 PLEASE COMPLETE ALL OUESTIONS NAME oF BUSINTss Ancha( lce \btdaace' €39g - 3aqrBUSINESS TEL, " 50 g - BUSTNESSADDRESSTNyARMouT,I l3o 5 R-:e Al verlruceoonrss.l 8a>ttt a( EMAIL ADDRESs J rTr acn^.6n +@ a,twxwlhtx du;<fe.cCrn dlo bq RT]OT. I RFD MANAGER/CONTACT PERSON r.n C(\a.a TELEPHONE #va56.- 3tq t RT'OI IRI'D OWNER NAME-\.o^rr n€- L.-r:rrr ( HOMEADDRESS \ CORPORATION NAME (IF APPLICABLE)a,f I t,.n h+ +nc- rct.t W-)f,8-o 1cD Q-+Maat(Y- coRPoRATroN ADDRESS t 3L e-cee'lr 4n uetllNG Roonrss 1 S + t{* 3 LICENSES RLIN ANNUALLY FROM JULY I TO JTNE 30. IT IS YOTJR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLNE 30. FAILURE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT I.NTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED, A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQIJ'IRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes_[ no_ rVa_ 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 .4ffidayit. If nol a licable, please explain q REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED )< NALL SAFEry DATA SHEETS oNFILE X YNANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT, APPLICANT'S SIGNATURE DATE u\aolaoa5 TAx ID (FEIN oR SSN)REOUIRED RENEWALAPPLICETION ( NEWAPPLICATION ;.- -The Commonwealth of Massochusetts Dep artm en t of I n d u strial A ccide n ts Ollice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I l-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses p Applicant Information Please Print Leeiblv Address \3o5 -R.ot &V k:.n o 3,"c.tnqr, lrurg.)a.ce_ CitylState/Zip:>+, Tff.,??to{ 56l. jqg-3u t 1 Business Type (required) Retail RestaurantBar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care 5. 6. 1. 8. 9. l0 ll E t2.! Other Ar€ tou an employer? Check the appropriate bor: I am a sole proprietor or partnership and have no employees working for mc 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]+ We are a non-profit organization, staffed by volunteers. with no employees. [No workers' comp. insurance req.] 2. t- 4. enrployees (f'ull and/t.$ I am a enrployer with or part-time).* I am on employer that is providing workers' compensation insurance lor my employees. Below is the policy information.--I-oNI€ \ecS lnsurer's Address CitylStateiZip \-U-rt-f-r-a-. c-\- 6 \ 02- Policv # or Self-ins. Lic. #bHu04d61,{-b-?,1+Expiration Date: Attach a copt- of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secwc coveragc as required under g 25A ofMGL c. 152 can lead lo the imposition ofcriminal penalties ofa tine up to S1,500.00 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 advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t lao I do hereby cenify, under the pains and penulties of perjury that the information provided aboye is true ond corrccl S a Phone #::o<-fa,r- on@ Dat b 6 lssuing Authority (check one): lfiBoard of Health 2.! Building Departm€nt 3.E City/Town Clerk Permit/License # 4.ELicensing Board Phone #: 5[ Selectmen's Ofiice 6. Eother Contact Person: www.mass.gov/dia Business/Organization Name: 'Any applicantthat checks box #l must also fillout the section below showing their workers' compensation policy information. *+Ifthe corpo.ate officers have exempted themselves. but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. Insurance Company Name: Official use only'. Do ,tot write in lhis area, to be completed by cit)' ot town ollicial. Citv or Tou n: Information and Instructions Massachusetts Ceneral Laws chapter 152 requircs all cmployers to provide workcrs' compensalion for their employees Pursuant to this statute. an employee is defined as "... every person in the service of another under any contract of hire, express or implied, oral or udllen." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal represenlatives of a deceased employer, or the receiver or trustee ofan individual, partncrship, association or other lcgal entity. cmploying employees. Howevcr, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe 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 employment be deemed to be an employer." MGL chapter I 52, $25C(6) also stales that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opcrat€ a business or to construct buildings in the commonwealth for any applicant who has not produc€d acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the cornrnonwealth nor any of its political subdivisions shall cnter into any contract for the performance ofpublic work until acceptable evidence ofcompliancc with the insurance rcquircmcnts of this chaptcr have bcen prcscnted to thc contracting authority." Applicants Please fill out the 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 of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees othcr 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 lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit, The affidavit 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 if you 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 the affidavit is complcte and printcd legibly. The Department has provided a space at the bottom of the aflidavit for you to fill out in thc cvent the Office 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. ln addition, an applicant that musl submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affrdavit that has been officially stamped or marked by the city or town may be provided to the applicant a: proofthst a l'alid affida.,'it is on file for future permits or licenses. A ncw afldavir 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 license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Oflice of Investigations would likc to thanl you in advance for your coopcration and should you have any qucstions, 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 Offi ce of Investigations Lafayette Ciry Center 2 Avenue de Lafayette, Boston. MA021ll-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 Form Revised 712019 www.mass.gov/dia .-. TRAVELERS J INSURER: THE TRAVETJERS TNDEMNTTY coMpA.}ry oF .AMERTCA A STOCK COMPANY 1. INSURED WORKERS COMPENSATION AND EMPLOYERS LIABILIry POLICY ryPE AR INFORMATIoN PAGE WC OO OO 01 ( A) POLICY NUMBER: ( 5HlrB - 4N874 E 3 - 6 - 24) RENEWA.L OF ( 5r{uB_4N87 463 _ 6 _23) NCCI CO CODE: 1343 9 PRODUCER: RISR STRATEGIES CO 160 FEDERAL STRTET FtooR 4 BOSTON MA 02t 10 I !,IARINE LUMBER OPERATOR INC DBAMARINE HOME CENTER & DBA134 ORANCE STREET NATflTUCKET MA 02554 lnsured is A MULTrpr.E srArus other work praces and idenrfication numbers are shown in the schedure(s) attached.2' The policy period is from L2-L8-24 to 12-18-2s 12:01 A.M. atthe insured,s mairing address 3' A' WORKERS COM'ENSATTON TNSURANCE: part one of the poricy appries to the workersCompensation Law ofthe state(s) listed here: - ' - '' MA B EMpLoyERS LrABrLrry TNSURANCE: part rwo of the poricv appries to work in each state listed initem 3.A. The Im[s of our habilrty und; part i*o "i",'"" '""', ' Bodily ln.lury by Accident: S soOooo Each AccidentBodily tnlury by Disease: S sooooo eotrcy fimltBodity tnjury by Drsease: S sooooo r"lfirrpilv"" orHER STATES TNsURANCE: part rhree of the poricy appries to the states, if any. risted here:COVER,T,GE REPLACED BY ENDORSEMENT I{C 20 03 O5B c. D. This policy includes these endorsements and schedules: SEE LISTING OP ENDORSEMEMTS - EXTENSION OF INFO PAGE 4. DATE OF ISSUE: OFFICE: PRODUCER: 72-02-24 wc RMD POOL 151RISK STRATEGIES CO The premium for this policy will be determined by our Manuals of Rules, classifications, Rates and RatingPlans Alr required information is subiect to *rm."ti"n "noliJnge uy audit to be made .i\NNrrALry. 523 7 623s S? ASSIGN: MA