HomeMy WebLinkAbout2025-26Crh No oq85
LICENSE FEE $I5O 6*vu-zs-rV4
OF YARIIIOUTH BOARD OF HEALTH
AND STORAGE OF TOXIC OR HAZAR"DOUS I\IATERIALS
LICENSE APPLICATION
COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE
BY .IIINE 30. 2025
.S,SCAIIliiD
NAME OF BUSINESSZlur ?ocL?r o{r BUSINESS TEL. #t =ip')zqKvq(ozRooBUSINESS ADDRESS IN YARMO 9
tsEGrE0vtrD
JUL 2 8 2025ro
0214242J,#$qfL\G
EMATLADDRESs C DAALE@REDIALkr-r Rr--S vIS, CONI.
&EQ!.d RED MANAGER/CONTACT PERSON
TELEPHONE #\Z(
CORPORATION NAME (IF APPLICABLE)tr6a$.,<iikJ r*."
EEOIJIBED OIVNER NAME TEL.#-
HOMEADDRESS
TEL. #
CORPORATION ADDRESS
TAX ID (FEIN OR SSN)REOUIRED ?f;-3tt084?
LICENSES RUN ANNUALLY FROM JI-]I.Y 1 TO JUNE 30. IT IS YOTJR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQIJIRED FEE(S) BY JUNE 30. FAILIjRE TO DO SO WILL
R.ESULT IN CLOSURE OF YOI]R ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) A]VD
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQT]IRED PzuOR
TO REOPENING.
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check
appropriately ifpaid: yes_ no_ rtla_
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 ofyourpermits, you must complete the enclosed Workers
Compensation Affidavit. Ifnot applicable, please explain
REGISTRATION FORM SIGNED AND COMPLETED
C}IECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SMETS ONFILE.yN
ANY NEW CHEMICALS MUST BE PRE-APPROVED BY TIIE HEALTH DEPARTMENT.
NY
APPLICANT'S SIGNATIJRE DATE
PLEASE COMPLETE ALL OUESTIONS
VATLNG ADDRESS Sarn(
MAILING ADDRESS
2L
RENEWAL APPL "O,,O*
/ NEW APPLICATION-
The Commonwealth of Massachusetts
D epartment of Industrial Accidents
Office of Investigations
Lafayette CiA Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gou/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Orsanization Name :
Address:
CitylStatelZip:aLbf#n"*,3
*Any applicant that checks box #l must also fill out the section below showing their workers' compensatioo policy infomation.
*rtf tlr" "orporat om"ers havc exempted themselves, bu! thc corpomtioB has other employccs, a workers' compensation policy is required and such an
organization should check box # I
Are you an employer? Check th
I am a sole proprietor or parhership and have no
employees working for me in any capaciry.
[No workers' comp. inswance required]
We are a corporation and its officers have exercised
their right ofexemption per c. 152, $ l(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.]
4.E
,F
2.E
.tr-r. L__.1
€ appropriate box:
employees (full and/I am a employer with
or part-time). *
Business Type (required):
5. E Retail
6. ! Restaurant tsarlEating Establishment
7. E Office and.ior Sales (incl. real estate, auto, etc.)
8.
9.
l0
ll
t2 Other
Non-profit
Entertaifinent
Manufacturing
Health Care
I am an employer thtt is provi(ling norkers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address t1 L, l)6n TloJro"-t Dnrrr
City/State/Zip:
Policy#orSelf-ins.Lic.# Y-I-WC OSIOO (oOO ExpirationDate:q
Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date)'
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 statement may be forwarded to the Office of Investigations of
the DIA for insurance coverage verification.
I do hereby certify, under the pait s tnd penalties of perjury that the information provided above is true and correcl
Signature:Date
Phone #:
OfJicial use onty. Do not wite ih this area, to be completed by cig or town official.
Issuing Authoritv (check one):
tflrJara of Heatin z.E rulaing Department 3.8 City/Town Clerk 4.LLicensing Board
Phone #:
Citv or Town:Permit/License #-
'5[ Selectmen's Office 6, EOther
Contact Person:
www.mass.gov/dia
Applicant Information Please Print Legiblv
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