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Home My WebLink About2025-26lo a,rc{#11 LT.ENSE.r,s,:uBtL[M :,]! 3 7 ,rtrRst+\1"" *,ili:0TOIVN OF YARNIOUTH BOARD OF HEALTH 202512026 HANDLINC AND STORAGE OF TOXTC OR HAZARDOUS LICENSE APPLICATION CO]\IPLETE THIS APPLICATION AND R.ETLTRN IT WITH THE BY JUNE 30. 2025 PLEASE CONIPLETE ALL OUESTIONS NAME oF ausnvess&ssRiv<r D-t(. d6.\lt)r-tOBUSTNESS rEL. # BUSINESS ADDRESS IN YARMOUTH $**t"yvo,r-*L \vta oztr4 JUN 18 2025 a tr@ MAILING ADDRESS box Jz)o1-Yt".r*-tt.YYl OZGG + EMAIL ADDRESS ,CO REqL.[BED MANAGER/CONTACT PERSON nvttQ-Cct y1y16,,^ TELEPHoNE# fu8 - 314 -52-82 TEL,#5D \.L^a QA lLnJt.Lo,oct .r4na- C)1n4i." ..^tBEQJJIBED OWNER NAME HOMEADDRESS 50 r--I CORPORATION NAME (IF APPLICABLE)- CORPORATION ADDRESS MAILING ADDRESS &vne, A^s horvre, TEL. # rAx rD (FEIN oR ssN) REOLIIRf,D 5 LICENSES RLIN ANNUALLY FROM JULY I TO JTINE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQU]RED FEE(S) BY JLNE 30, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S)AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yes_ no_ rla- Under Chapter 152, Sec. 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affidavit. If not applicable, please cxplain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKIRS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE vY N N ANY NEW CHEMICALS MUST BE PRE.APPROYED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION APPLICANT'S SIGNATURE DATE 2s* F #Lr { NEW APPLICATION The Commonwealth of Massachusetts D epartm ent of I n dustrial A ccide n ts Oflice of I nvestigatio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I l-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses t--1 Business/Organ ization Name3Rr-s R, vqr Dr..LS ltp*ca YYbrrn Q Address: ?o llox 4S City/State/Zip:vnorJL q o%6$von,x, €otr -1?y' -szP< Business Type (required) s. ! tctail 6 7 8 9 RestauranL/Elar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment 10.! Manufacturing I l.! Health Care r2.Er other Coy\gt(^c^c OY\ tAny applicaot that checks box # I must also fill out the section b€low showing their workers' conrpensation policy information. t.Ifthe corporate officers have exempted themselves. but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. Are you an employer? Ch€ck the appropriate box: or part-time). * I am a sole proprietor or partncrship and have no employees working for me in any capacity. INo workers' comp. insurance required] f. E We are a corporation and its officers have exercised their right of exemption per c. 152. ! I (4), and we have no employees. fNo workers' comp. insurance required]* +. ! We are a non-profit organization. staffed by volunteers, with no employees. [No workers' comp. insurance req.] G 2,8 employees (full and/l.E I am a employer with I am an employer that is providing workers' compensotion insurtnce for my employees. Below is the policy information, Insurance Company Name: Aa lnsurer's Address:s4 l<4 City/State/Zip C> Policy # or Self-ins. Lic. #Expiration Date llrs (S- Attach a copl- of the workers' compensation policy declaration page (showing the policy number and expiration date). I Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa fine 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 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 the DIA for insurance coverage veriltcation I do hereby cenify, under the pains tnd penalties of perjury that the information provided above is lrue and conecl -1Si str -..q+- 523aPhone # Ollicitt use only. Do nol wite in this area, to be completed by cit or town otficial' 5[ Selectmen's Oflice 6. Eother Permit/License # Phone #: 3.8 City/Town Clerk 4.ELicensing Board Contact Person: Cilv or Tonn: Issuing AuthoritY (check one): lEBoard of Health 2.flBuilding Departm€nt ww\r.mass.gov/dia Applicant Information Please Print Lesiblv Arto, Information and Instructions Massachusefts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this stat.llte, an employee is defined as "...every person in the service ofanother under any contract ofhire. express or implied, oral or written." 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 Iegal representatives of a deceased employer, or the receiver or trustec of an individual. partncrship, association or other legal entity, cmploying employees. However, 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 employcr." MGL chapter 152, $25C(6) also states that "€very 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 ecceptable evidence of compliance with th€ insurance coverage required." Additionally, MGL chapter I 52, $25C(7) slates "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pcrformance ofpublic work until acceptable evidence ofcompliance with the insurance rcquircments of this chrpter havc been prcscntcd to the contracting authority." Applicants Please till 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 wrth 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 Departmenl of Industrial Accidents for confirmation of insurancc 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 lndustrial 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 listcd below. Self-insurcd companies should enter their self-insurance license number on the appropriate lins. City or Town Oflicials Please be sure that the afldavit is complcte and printed lcgibly. The Department has provided a space at the bottom ofthe affidavit for you to lill out in the 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. In addition. an applicant that must submit multiple pcrmit/licensc applications in any given ycar, need only submit onc affidavit indicating currcnt policy information (if necessary). A copy of the affidavit that has been olficially stamped or marked by the city or tovn may be provided to the applicant as proolthat a valid a{fidar.it is on file 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 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 office of Investigations 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 The Department's address, telephone and flax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7i 2019 WWW.maSS.gOV/dia iGo" COVERAGES CERTIFICATE OF LIABILIry INSURANCE CERT|F|CATE NU BER: 1115524 REVISION NUMBER: o lE (rr/Do/YYm 05to7 t2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OTILY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OOES NOT AFFIRiIATIVELY OR NEGATIVELY AMEND, EXTENO OR AITER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO REPRESENTATTVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certi{icate holder i6 an AODITIONAL INSURED, the policy(ies) must hav6 ADDITIO AL INSUREO provision3 or bo endorsed lf SUBROGATION lS WAIVEO, subioct to the t6fms and condltlons ot tho policy, certaln policies mey requirc an ondorsemont. A statomont on ,his certiflcale does not conter rights to ths certlffcate holder ln lieu of such ondorsement(s). PRODUCER BALDWIN KRYSTYN SHERMAN PARTNERS LLC RG SBC (508) 760-4604 rgsbc@rogersg ray.com 4211 West Boy Scoul Blvd Suite 800 Tampa FL 33607 AIM MUTUAL INS CO 33758 II{3URED SASS RIVER DOCKS LLC INSURER B INSIJRER C PO BOX 483 S YARMOUTH MA 02664 IHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOIfl HAVE INDICATEO, NOTWI}ISTANOING ANY REOUIREMENT. TERM OR CONDITION OF CERTIFICAIE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO BEEN ISSUED TO THE INSURED NA}'ED ABOVE FOR THE POLICY PERIOD ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS BY THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NU BER EACH OCCI'RRENCE s MED EXP PFRSONAL I AOV INJURY 3 PRODUCTS. COIUP/OP AGG GENERAAGGREGATE COT'fERCIAL GEI.IERi L LIABIUTY G€N! AGGREGATE UMIT APPLIES PEREffi E.o" OCCUR MII BOOIIY IiUURY (Pd p66o.)$ sEOOltY lt{.lURY (Ps .cod.nl)OWNEDAUTOS ONLY HIREDAI.'TOS ONLY UTOXOBILE LIABlLIft SCHEDU!EOAUIOSNON.OWNEO AUTOS ONLY O@UR CLAIMS.IllADE EACH OCCURRENCE AGGREGATE UTBREILA IIA6 E CESS LlA8 x 3 500,000 3 500,000 E,I., EACh ACCIOENT E,t. OISEASE. EA EMP 500,000 0911512025 E,L, OISEASE. POLICY LIMII 09115t2024AWC40070396962024A ERATIONS ANYPROPF]ETOR/PAiTNER/EXECUTTVE OFFrcER/rf, IISER EXCTUOEO? v90RKERS COrlPEr{SATlOt AXO ETPLOYERS' LIABILITY OESCRIPTION w.*m, comEnsatirn b€nofitE vJi be Dad lo irassedru6etts €mptoy6e6 only. pursuant to Endorsom€nt wc m 03 06 B, m oufbrization i6 given lo pay daims fo. bonefl6 lo ;;6;i;;;"dG. u"s""a'i"em r r* insu|Ed hir€s, or has hi'€d tho€e €mpbFe! drEi'e ot Mr8st"uselts' c.rtfceto of tn"ursnce). Th€ statu6 ot tris covoffi#L;;ffi;;"dy il;"#lrB ii Fioot.t cown{ze'covoage vorif'cadon s€a.dr tool at w** mtss qov/}'diio'ters- componsallodinvgstgetion6/, Continuaton ol above Nsrn€d lmured: LEMCO DESCR|mO OEOPER nOX3/LOCAnOils/VEHICIES (ACORO lol Addtdonrl L.m.rlq s.h.dul.. my b. ti.ch.d ll froE.p.€ I. r.qurEd) CANCELLATIONCERTIFICATE HOLDER @ 198E-2015 ACORD CORPORA SHOULD At{Y OF THE ABOVE DESCRIBEO POUCIES BE CAI{CELLED BEFOREiii exprurron oarE THEREoF, l{orlcE wlLL BE oELNEREo lt{ ACCOROA},ICE WITH TXE POUCY PROVISIONS. l--r c-8. Danid M. Cro*$Y CPCU, Vice Presidonl - Residual Market - WCRIBMA AUI}IOREEO REPRESENTATWE FOR INSURANCE PURPOSES ONLY PO Box 483 MA 02664South Yarmouth ACORD 2s (2016/03)The ACORD namo and logo are registored marks of ACORD TION. All righls rGorved, t{!ru8El{g) af f oiq o covERAoE_ s $ $ $ $ N/A E