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Home My WebLink About2025-26JUr , [dV,l o. BtrG /'iir:- = rBs+ND26HE{DL Ih-Na' /S-/7 202 PLE.ASE COMPLETE ALL QUESTIONS NAME ol- BUSTNESS 6e.lk "r-Ti lp. $ [t\or b\e- +1, LI('E\SE,\PPLIC',\TIO\ CONIPLETE THIS APPLICATION A\D RETTIRN IT \\'ITH THE LICENSE FEE BY JUNE 30. 2025 YARNIOUTH BOARD OF HEALTH TORAGE OF TOXIC OR HAZARDOUS MATER]ALS €scmtim BUSTNESSTEL. * 508 t'15 1666 LICENSE FEE SI50 gapy-2s-r*l BUSINESS ADDRESS IN YARMOU MAILTNG ADDRESS I t '73 o EMAIL ADDRESS b *i . Con^ REOU I RI'D MANAGER/coNTACT PERSoN 5ar-,t g €Lc e TELEPHoNE # fot-3zf - :ps o RFOLiIR1-D owNERNAME,)ornu Bpltr-u,.r TEL,# HOME ADDRESS & ,,ro.f H,Lu RDz E. ,'A^(DLitcFl, rr< r+ s.1Sl7 CORPORATION NAME (IF APPLICABLE) TEL. # CORPORATION ADDRESS MAILING ADDRESS luL lfi ?025 uu(.9 @ DEPTHEAI.7H TAX ID (FEIN OR SSN)REoUTRED 8J- Sr ttrJly LICENSES RUN ANNUALLY FROM ruLY I TO ruNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION1S) AND REQUIRED FEE(S) BY JT,NE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LINTIL THE RTQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFOR-E THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENINC. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes "/' no_ nla- Under Chapter 152, Sec, 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal of any license or permit lo 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. Dlease explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVITENCLOSED ,/ NANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENE*AL Appl,corro* / NEw AppLrcATroN APPLICANT'S SIGNATURE DATE: The Commonwealth of Massachusetts Department of Industial Accidents Office of I nvestig ations Lafayefte City Center 2 Avenae de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses & Annlicant Information Please Print Lesiblv Business/Organi zation Name: 0t-\\t rif -Ii\t S Mo-rt \t- aodress: d BO 0.oott - JB CitylStatelZip: 2 Are you an employer? Check the appropriate box: l. p[ I am a employer with l'{ employees (tull and/ 4.fl or parttime).* I am a sole proprietor or partnership and have no 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, g l(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.] blbPho"e+: Business Type (required) 5. ffietatt 6. 7. 8. 9. 10. ll. t2. RestauranL/Bar,/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care Other *Any applicant that checks box #l must also fill out the section below showing their worker' compensation policy information**lf the corporate officers have exempted themselves, but the corpomtion has other employees, a workers' compensation policy is required and such anorganization should check box #l I am u employer that is p Insurance Company Name roviding workers' compensotion insumnce for my employees, Below is the policy information.ALq Hnarrf Insurer's Address: 6,..,1€- BA(f 6d\-D QL'r-^ac City/State/Zip HFrrre.;cc> , cT- 661 {, I do hereby certi der the pains and penalties ofperjury thst lhe informotion provided above is true ond correct. Date 6 es r hone #5-oB-)- Slos lssuing Au thority (check one): I LlBoard of Heatth 2.E Buit(s{-l serectmen,s orn"" u. nolirX'. Department 3rl city/Town clerk Permit/License # 4.DLicensing Board Phone #: ofrt write iu ofJici.actI u ose Do ol t,h .t11,.aret beto c o olt'nt,completed by at. Contact Person: Citv or Town: w1hv. mass.gov./dia Policy # or Self-ins. r-ic. + T6v.JEGAxl t AYI{ Exptration late: l/l /}6Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failurc to secure coverage as requircd under $ 25A of MGL c. 152 can lead to the irnposition ofcrirninal penalties ofa fine upto s1,500 00 and/or one-year imprisonment, as well as civil penalties in the form of a sTop woRK oRDER and a tine of up to$250'00 a day against the violator' Be advised that a copy oithis statement may be forwarded to the office of Investigations ofthe DIA for insurance coverage verification. Information and Instructions Massachusetts General Laws chapter 152 requircs all employers to provide workers' compcnsation for their employees. Pursuant to this stattte, at employee is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written." A1employer :.s delined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the recciver or trustee ofan individual, partncrship. association or other legal entity, emplolng 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 of another who employs persons to do maintenance, construction or repair work on such dwelling house or on thc grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter I 52, $25C(6) also states that "€verv state or local licensing agency shall }}'ithhold the issuance or renewal of a license or permit to operate a business or to construct buildings in thc commonwealth for any applicant who has not produc€d acceptable evidence of compliance with the insurance coverage required." Atlditionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enler into any contracl for the performance ofpublic work until acccptable evidencc of compliance with thc insurance rcquiremcnts cf this chapter have bccn presentcd to tbe 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 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 aflidavit, The affidavit should be returned 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 ifyou 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 appropriate line. please do not hesitate to give us a call rhe Department's address' telephone Tt :"b::1i1"*earth of Massachusetts Department of Industrial Accidents Office of Investigations LafaYette CitY Center 2 Avenue de LafaYette, Boston, MA021l1-1750 Tel. (857) 321-'7406 or 1-877-MASSAFE Fax (617) 727-'7749 www.mass'gov/dia Form Revised 7/2019 City or Town Officials please be sure that the affidavit is complete and printed lcgibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the evcnt the Office of Investigations has to contact you regarding the applicant. please be sure to hll in the permit/license number which will be used as a reference number. ln addition, an applicant that must submit multiple permit/license apptications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the alldavit that has been officially stamped or marked by the city or town may Le provicled to the applicant as prcofthat a valid affidavit is on file for future permits or licenses. A new affidavit aurt ba'fillad out "ach 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 advance for your cooperation and should you have any questions,