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Home My WebLink About2025-26r:.i-:: i:-' JUL rl 3 ?O?5 HEATTH D E P'].,tO h.t$o N()2{13 LTcENSE FEE sr50 611ry1r,-231942 N OF- \'AR}IOUTH BOARD OF HEALTH AND STORAGE OF TOXIC OR HAZARDOUS M.,ITERIALS LICENSE APPLICATION COIIPLETE THIS APPLICATION A),ID RETTIRN IT \\ITH THE LICENSE FEE BY JUNE 30, 2025 PLEASE COMPLETE ALL OUESTIONS NAME OF BUSINESS BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS turl €scrum BUSINESS TEL. #Ll 0 02q1 "3 EMAIL ADDRESS REOT, IR[,D MANAGER/CONTACT PERSON TELEPH.NE# {oA tlto o}9q N\4 M oo,oft) (ytwrl RFOUIRFN OWNER NAME HOME ADDRESS TEL.# CORPORATION NAME (IF APPLICABLE)-TEL. # CORPORATION ADDRESS \1-{It-IN(; ADDRESS rAX rD (FEIN on ssNlBE@IED oL{-6'{lG888 LICENSES RTIN ANNUALLY FROM JULY I TO JTINE 30, IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LTNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARI RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENINC. Town of Yarmouth taxes and liens must be paid grior to renewal or issuance ofyour permits. P|ease check appropriatell if paid: yes_ no_ n rL- Under Chapter 152, Sec. 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal ofany license or permil Io operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits. you must complete the enclosed Workers Compensation Affidavit. If not applicable, please explain RTGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK-ERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ONFILE N Ai'iI' NE\\' CHEMICALS NIUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION N APPI-ICANT'S SIGNATI IRE NEW APPLICATION I ++ DATE: The Commonwealth of Massachusetts D epartm ent of I n d u strio I Accidents Ollice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I I-1750 www.mass.gov/dia E- A Workers' Compensation Insurance Affidavit: General Businesses licant Information Please Print L Business/Organization Name :,Uw1 S Address:r)L CirylStatelZip: ?>, 5oA-ho. 6LqqPone # bl Business Tvpe (required) 5 6 Retail RestaurantBar/Eating Establishment 7. fl Office and/or Sales (incl. real estate. auto, etc.) It. 9. t0 Non-profit Entertainment M anufacturin g Health Carern ,=s LOtherV\r *Any applicant that checksbox #l must also fill oul the section below showing their workers' compensation policy information.**lfthe corpomte officers have exempted themselves, but the corpomtion has other employees. a workers' compensation policy is required and such an organization should check box #1. Ar€ vou an employer? Check the appropriate box: 2 J 4 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. $l(4), and we bave no employees. [No workers' comp. insurance required]+* We are a non-profit organization, staffed by volunleers, with no employees. [No workers' comp. insurance req.] $ro am a employer with r part-time).* employees (full and/ I am tn employer that is p Insurance Company Name lnsurer's Address: [0O rovidin workers' compensation insurance for my emplol,ees. Below is the policl, inlormation. .\^gr{( ?0 56w City/State/Zip OCID 6cso Policy # or Self-ins. Lic. # Attach a copy of the workers' compensation policy declaration page (showin Expirationr",., W|&nlr l\ l6 g the policy number and expiration date). f5 Failure to secure coverage as rcquired under 6 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisoment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of upro $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the office of Investigations ofthe DIA for insurance coverage verification. I do hereby ture ne# the pains and penalties ol perjury that the infornation provided aboye is true and correct. Dat to o7q z Official use only. Do not wite i this area, to be completed by ci4, or 166,11 61V"1o1. lssuing Authority (check one): I [Board of Heatth 2.! Buitding5E Selectmen's Office 6. Eother Contact Person: Department 3f-lCiry/TownClerk 4.ELicensingBoard Phone #: www.mass.govldia Permit/License #Citv or Town: Information and Instructions Massachusctts Gcneral Laws chapter 152 requires all cmployers to provide workers' compensation for their cmployees Pursuant to this statute. an employee is detlned 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 ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer. or lhe receiver or trustee ofan individual, partncrship, association or other lcgal entity, employing cmployecs. However, the owner ofa 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, conshuction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be dcemed to be an employer-" MGL chapter I 52, g25C(6) also states that "every state or local licensing agency shall withhold the issuance or rcnewal of a license or permit to operate a busincss or to construct buildings in the commonwealth for any applicant who has not produced acceptabl€ evidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the corffnonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acccptable cvidence of compliance with the insurance rcquiremcnts of this chapter have been prescntcd to thc 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 cmployees othcr than the members or partners, are not required to carry workers' compensation insurance. If an 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 affidavit. Thc affidavit should be retumed to the city or town that the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any queslions regarding the law or if you are required to obtain a workers' compensalion policy. please call the Department at the number listed below. Self-insured companies should entcr their sclf-insurance liccnse number on the appropriate line. City or Town Officials Plcase bc sure that the affidavit is completc and printed legibly. The Depanment has provided a space aI thc bottom of the a{fidavit for you to fill out in thc cvent thc Office of Investigations has to contact you rcgarding 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 permit/license applications in any given year, need only submit onc aflidavit indicating currcnt policy information (ifnccessary). A copy ofthc affidavit that has been oificially stamped or marked by the city or town may be provided to the applicant as proof that a valid allidavit is on file for fuhue permits or licenses. A new affidavit must be filled out each year. Where a home owncr or citizen is obtainrng a license or permit not related to any business or commcrcial venture (i.e. a dog license or permit to bum leaves etc.) said pcrson 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 Ti.3L:HHr*ealth of Massachusens Department of lndustrial Accidents Oflice 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/diaForm Revised 7r2019