HomeMy WebLinkAbout2025-26(h.t'to, fid
LICENSE FEE S15O 6t/t/tt-2,{'fu
OF YARMOUTH BOARD OF HEALTH
AND STORAGE OF TOXIC OR HAZAR.DOUS MATERIALS
LICENSE APPLICATION
COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE
BY JI]NE 30, 2025 ,/a\<e Ds
i A t!tt.
rg.Lri rrPLEASE COMPLETE ALL OUESTIONS
NAMEoFBUSTNEss Rlu-a\[)a{tr,- Q....,n-t-
BUSINESS ADDRESS IN YARMOUTH
BUSINESS TEL, #kw\zqY-t2x5
JUt 2 B 2025
02
TO\
olg'.,..L=\Jtr
o
Ei!trA.IL ADDRESS D G
BEq!J!BED MANAGER/CONTACT PERSON
TELEPHoNE# 16 11\ (aXU - \r 3 r-
BEQIJIBEDOWNERNAME TEL.#
CORPORATION NAME (IF APPLICABLE)
CORPORATION ADDRESS
HOME ADDRESS
TEL. #
rAx ID (FEIN- oR ssN)BglUIBlqD B 3- b\508+N
LICENSES RIIN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOTJR RESPONSIBILITY TO RETURN
TTIE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESULT IN CLOSIJ'RE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) aR5 pggEIVED. A HEARING BEFORE THE BOARD OF IIEALTH MAY BE REQLTIRED PzuOR
TO REOPENING
Town of Yarmouth taxes and liens must be paid prior to ren€wal or issuance ofyour permits. Please check
appropriately ifpaid: yes- 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 part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers
Compensa tion Affrdayit. Ifnot applicable, please explain:
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ONFILE.yN
.ANY NEW CHEMICALS MUST BE PRE-APPROVED BY TIIE IIEALTH DEPARTMENT.
RENEWAL APPLICATION
N
APPLICANT' S SIGNATI]RE
MAILINGADDRESS < AflTff
MAILING ADDRESS ,61T 4A{
NEW APPLICAT]ON-
DArE T/2r/bf
The Commonwealth of Massachusetts
D eparfinent of I ndustrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gou/dia
Workers' Compensation Insurance Aflidavit: General Businesses
-4.pp lica nt I nformatio n Plcase Print Lesiblv
Business/Organiza tionName: BlUe l,fr)o*<r ?rsort-
Address: Lq\ (,r.rLr,l S,tr o(c bnw
CitylState/Zip:one #:-L
*Any applicant thal checks box #1 must also fill out the sectio[ below showing their workers' compensation policy in oll
*{lf the corpoiate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is requiled
organization should check box #L
and such an
I am a employer wi tn lL "^ployees (full and/
or part-time).*
I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insuance required]
We are a corporation and its offrcers have exercised
their right of exemption 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.]
Are
I
)
3
u an employer?k the appropriate box:
4.fl
Business Type (required):
5. fl netail
6. I Restauranttsar/Eating Establishment
Office and,/or Sales (incl. real estate, auto, etc.)
Non-profit
Entertainment
Manufacturing
IZ Other C
ll.E Health Care
7.
8.
9.
l0
I am an employer that is ding workers' compensation ce for my empltnsuran s. Below k the policy information.
Insurance Company Name:
Insurer's Address tdtcr)L, DonD *{.n.r -Dnw
City/Statelzip:
poricy#orSelf-inr.Li..# vTwC (?3\aoGoo ExpirationDate LT
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 of a 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 Investigations of
the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the info nation proitled above is true and coftect
Sisnature: Date:
Phone #:
Olficial use only. Do not wrile in this area, to be completed by city or town official
Issuing Authority (check one):
lflBoard of Health 2.! Buitding Department 3^! CirylTown Clerk
Permit/License #
4. ELicensing Board
Phone #:
Citv or Town:
5E Selectmen's Office 6. Eother
Contact Person:
ww,lr.mass.gov/dia