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Home My WebLink About2025-266Y\Hu-r=-l7(L5 ', TOWN OF YARMOUTH BOARD OF HEALTE.. z02stz026HANDLrNc AND sroRAGE oF Toxrc on HazlRfiE$ElltEoam LICENSE APPLICATION CO]!TPLETE THIS APPLICATION AND RETUTr* TT WTTTT TilflT-ICEN8&5FEE PLEASf, CONIPLE ALL OUESTIONS NAME OF BUSINESS BIJSINESS ADDRESS IN YARMOUTH /->gscAlilrED HEALTH DEPT. -??l -a+3.lo$lUSINESS TEL t3 I t rht]r_,s ?r*fh , So. rlr'rsr.'.% rlftO^ r"l MAILINGADDR'" ?. EMAIL ADDRESS REOUIRED MANAGER/CONTACT PERSON TELEPHoNE #q sal.?ro+ RFOL'IRT'T) OWNER NAME TEL.#o HOME ADDRESS ur CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS ,ur.n ?Y1'3?3'etoK$ e \t IrMAILING ADDRESS oq-,u \qqqq LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQTNRED FEE(S) BY JLINE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIR.ED PRIOR TO REOPENING Town of Yamtouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check annronriatelv ifoaid: ves 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 pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compcnsation Affidavit. lf not applicablc,plcase explain REGISTRATION FORM SIGNED AND COMPLETED CIIECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE Y N A]{Y NE\\' CHEMICALS }IUST BE ,\PPROVED BY THE HEAt,TH DEP.{RT}IT]\T. RENEWAL APPLICATION N APPLICANT'S SIGNATURE NEW APPLICATION- DATE LICENSE FEE $ I50 BY JL'NE ]0. 2025 rAx rD (FErN oR ssN)BBIUIBED -/ The Commonwealth of Massachusetts D epartme nt of I n d u strial Accide nts OlJice of I nvestigation s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02lll-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ,fu ADplicant I nformation Pleasc Print l-eeiblv Business/Organization Name: Address: P O Ciry/Srate/Zip:Bttuhone #:15L 3+3,'t 68q Busiqrss Type (required): s. pxetait 6. ! Restaurant Bar/Eating Establishmenl 7 8 9 Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment 10.! Manufacturing I l.E Health Care .eny uppli*rrt ttrur "hecks box #l must also fill out th€ section below showing their workers' compensation policy information. *.ttih" "o.poat" om"ers have exempted themselves. but the corpo.arion has other employees. a workers' compensation policy is required and such an organization should check box #l ou an employer? Check the appropriat€ box: I am a sole proprietor or partnership and have no employees working for mc in any capacity. [No 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.] 3.E .+ employees (full and/ A re;( r16 2.4 I am a employer with or part-time).* I am an employer lhal is providing workers' tompensalion insurance lor my enl ktyees. Below is the policy information. Insurance Company Name lnsurer's Address Policy # or Self-ins. Lic. #6tLl(b < D120)YlrA Expiration Date: Attach a cop.!- of the workers' compensation policy declaration page (showing the policy number a piration date).Dd Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition ofcrinrinal penalties ofa finc 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 Frne 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. I do hereby Phone I ', under I ains and penalties of perjury thst the information provided ,.t e tnd cotect. /J Permit/License # Phone #: 3rl City/Town Clcrk 4.!Licensing Board Issuing Authority (check one): lflBoard of Health 2.E Building Department 5[ Selectmen's Offic€ 6. Eother Contact Person: www. mass. gov/dia t2.! other -City/State/Zip: Olficitl use only. Do not h,rite in this area, to be completed by city or town ouicial. Citv or Town: Information and Instructions Massachusetts General Laws chaptcr 152 requires all employers Io provide workers' compensation for their employces Pursuant to this *arnrc, ^a emplolee is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or wriften." 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 representatives of a deceased employer. or the receiver or trustee ofan individual, panncrship, association or olher legal entity, employing employees. However, the owner ofa 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 emplol,rnent be deemed to be an employer." 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 op€ratc 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 chapler 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pcrformancc ofpublic work until acceptable evidence of compliance with the insurance requirerncnts of this chapter have be3n prcscnted ta thc contractinE authoriry." Applicants Please llll 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 certificale ofinsurance. Limited Liability Companies (LLC) or Limitcd 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 coverage. Also be sure to sign and date the affidavit, The alfidavit should bc retumed to the city or town that the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any questions regarding lhe law or ifyou are required lo obtain a workers' compehsation policy, please call the Dcpartment at the number listed below. Self-insured companies should enter thcir sclf-insurance license number on the appropriatc line. City or Town Officials Please be sure that the affidavit is completc and printed lcgibly. The Departmcnt has provided a space at the bottom of thc aflidavit for you to fill out in the event the OITicc 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 thar must submit muhiple permit/liccnse applications in any given year, need only submit one affidavit indicating current 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 prcofthat a valid aIlida.,'it i-s on file for fuhrre permits or licenses. A new affidavit 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 lcaves ctc.) said person is NOT required to complete this affidavit. 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 Massachusetts Department of Industrial Accidents Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA021ll-1750 Tel. (857) 321-7406 or l-S77-MASSAFE Fax (617) 727-7'749 Form Revised ?i 2019 WWW.maSS.gOv/dia