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Home My WebLink About2025-26\6 crtf LICENSE I.'EE SI50 u J.,1 - )9r; TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION C'MPLETE THIS APPLICATI,N AND RETURN IT *ITH THE,,.BE€EE.I'!.\BY .lU.\-E -10,2025 /'1 SCAflI{ED JUN itj ZAIS 17,'itaw PLE.,ISE COMPLETE ALL QUESTIONS NAME OF BUSINESS SINESS TEL. # BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS 51 Md Teth Drtvc Atcsl farnoulh MA o"L-lb ' EMAIL ADDRESS e 0 e rn BE]Q]J.IED MANAGER/CONTACT PERSON Aobbu Dohcrh,l TELE'H.NE r 5a8. 5bq.q/t5 REOI- IRFN OWNER NAME Arlkur Doherlu,J r rct.a 5ol'lb'20qo HOME ADDRESS 4l htttcclct Pd /4arrT, u,tuulunk CORPORATION NAME (IF APPLICABLE)-TEL. # CORPORATION ADDRESS TAX ID (FEIN OR SSN)REOUIRED 3 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLTNE 30. FAILURE TO DO SO WILL RESI,'LT TN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEN'ED. 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-Yl no- n/a- 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 Cenification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Aflidavit. lf not applicablc, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED YN ALL SAFETY DATA SHEETS ON FILE ,/ YN ANY NEW CHEMICALS NIUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION NEW APPLICATION /./iPilC{qAPPLICANT'S SIGNATURE:d 0\t MAILINC ADDRESS o,ttl, U:LL:Z5 The Commonwealth of Massachusefts D epartme nt of I n dustrial A ccide nts Ollice of I nvestigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02III-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses a/ I le r5 Address: 57 l,ld fcth Dri,/. City/State/Zip:ltVcSl ''larm otL+h Ut o2{d,?"0 Are you an employer? Check the appropriate box: t.W I am a employer with 3 5 employees (full and/ or part-time ). * z. E I am a sole proprietor or pannership and have no 3 4 employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their right ofexemption per c. 152,$l(4),andwehave no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required) 5. ! netait 6. 7. 8. 9. l0 ll RestauranUBar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care n.flother ELcolnrul Con*Ydtto{ *Any applicant that checks box #l must also fill out the section below showing th€ir workers' compensation policy information. +*lf the corporate officers have exempred themselves, but the corporalion has other employees. a workers' compensation policy is required and such an organization should check box #1. lnsurance Company Name + lnsurer's Address ,0 AO 0 CitylSlare/Zip Policy # or Self-ins. Lic. #0 10 Expiration Date I do hereby ce Si rjury that the information provided above is true snd correct. ate b-t-15 Phone #x-11t-12-7 0 lssuing Authority (check one): I flBoard of Health 2.E Building5[ Selectmen's Office 6. Elother Contact Person: Department 3.E City/Town Clerk 4.ELicensing Board Permit/Lic€nse # Phone #: Citl or Town: www.mass.gov/dia Applicant lnformation Pleasc Print Leeiblv Business/Organization Name: 1) I am an enployer thot is providing workers' utmpensttion insuronce for my employees. Below is the policy information. Attach a copy of the workers' compensation policy declaration page (shorring the policy number and expiration date). Failure to sccrrre covcragc as required under $ 25A of MGL c. 152 can lead to the irnposition of criminal peualties 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 ofthis statement may be forwarded to the Office of lnvestigations of the DIA for insurancc coverage verification. OfJicial use only. Do not write in this area, to be completed by city or town of/icial. Information and Instructions An employer is defined as "an individual. partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enlerprise, and including the legal representatives ofa deceased employer, or lhe receiver or trustee ofan individual, partnership, association or other legal entity, employing employees. However, the owner of a 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 dwellrng 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 "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to op€rate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverege required." Additionally, MGL chapter I 52, 5r25617; t,u,"s "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract for thc pertbrmance ofpublic work until acceplable evidencc ofcompliance with the insurance req{iremcnts of this chrpter havc becn plcsc;rted tc tl:e contracting aulhorily." Applicants Please fill oul 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 ofinsurance. Limited Liability Companies (LLC) or Limited Liability Partncrships (LLP) with no employees other than the members or partners, are not required lo carry workers' compensation insurance. lfan 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 insurance covcrage. Also be sure to sign.nd date the affidavit. The affidavit should be retumed to the city or lown 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 numbcr listcd bclow. Sclf-insured companics should enter their self-insurance license number on the appropriatc line. City or Town Officials Please be sure that the afldavit is complete and printed legibly. The Departmcnt has provided a space at the bottom of the affidavit for you to fill 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 muttiple permiVlicense applications in any given year. necd only submit one affidavit indicating cunent policy information (ifnecessary). A copyof the affidavit that has bcen officially stamped or marked bythe city or rown may he orovided to the applicant as proofthnt a valid alfida'iit is on file for future pcrmits or licenses. A new affidavit must be filled out each year. Where a home owner or cilizen is obtainrng a license or permit not related to any business or commercial venture (i.e. a dog license or permit Io bum leaves etc.) 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 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 1 I -1750 Tel. (857) 32t-'7406 or 1-877-MASSAFE Fax (617) 727-7749 Form Reviscd 7/2019 www'mass'govi dia Massachusetts Gencral Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this s|:t:.fie, an employee is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written."