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Home My WebLink About2025-26"tiiiN ,{ .':I25, ' PLEASE COMPLETE ALI, OLTESTIONS €scmrro NAMEoFBUSTNESIcA?LQr6A4Ttfi<tli- l4LN*g G;fr.tBusrNESSTEL. * 588-3AZ^4955: BUSINESS ADDRESS ,*ro**o::nH Z1/s7,/ht OF YAR}IOTiTH BOARD OF HEAI-TH D S-TOR,A.GI] OF TOXIC OR HAZAR-DOL'S M-.\TERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30. 2025 5 \4SEwtl--MAILING ADDRESS EMAIL ADDRESS CI^IIJLL 1 tl),(onr REOUIRED MANAGEzucoNTAcTpERSoN BuL N,uz- RFOtrtRr,'t)owNnRNevrFlrstNutt mrUdt eW- NA TEL,#-b CORPORATION NAME (IF APPLICABLE)trMLNA rw.*78/'L??-?OO CORPORATION ADDRESS (So-r-* ,4 g4o(z) MAILING ADDRESS TAX ID (FEIN OR SSN)REOUIRED 04 - 308 9L60 LICENSES RLN ANNUALLY FROM JULY I TO JT,NE 30. IT IS YOUR RESPONSIBILIry TO RETURN THE COMPLETED APPLICATION(S) AND REQU]RED FEE(S) BY JLI'NE 30. FAILURE TO DO SO W]LL RESULT IN CLOSURE OF YOUR ESTABLISHMENT TJNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RTCEIVED. A HEARNG 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_[ 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 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 Compensation Alfidavit. If not apDlicable, Dlease explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AT'FIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE N ANY NE!!' CHEMICALS }IUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. N APPLICANT'S SIGNA NEW APPLICATION DATE eh.N.t2o1 LrcI,NSE r-Er, sl5() BHHTL|- %-fi'S rct-rpsoNr + 5a9'362 -1193 5 - s-o9' 7?A - 34q HoMEADDRESS Q20 NtiruP- {, WglztiAlu M4 izqfl - /15/ A,/RENEwAL APPLICATIoN UZ\- E,'{ The Commonwealth of Massachusefis D epartm e n t of I n du strial Acc i dents Office of Investigotions Lafayette City Center 2 Avenue de Lafoyelte, Boston, MA 021 I I-1750 www,mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organ ization Name: qPZ- coD WtFtc t *C- P I bl.t 2Y (t N(?l(\ Address:MT 2b City/StatelZip:Dnru+7 NA a Phone #:5Dv4b2-f.3t Are you an employer? Check the appropriate box: l. l am a employer with - employees (full and/ or parl-time).* 2. E I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4), and we have no employees. [No workers' comp. insurance required]** +.! We are a non-profit organization, slaffed by volunteers. with no employees. [No workers' comp. insurance req.] 'Any applicant that checks box #l must also fill oul the section b€low showing their workers' compensation policy information..*lf the corporate officers have exempted themselves, but the corpomtion has olher employees. a workers' compensation policy is requiaed and such an organization should check box #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy inlormotion. lnsurance Company Nane /AHQ3,I] /5 //c Insurer's Address I / bL 4vr/ut/L atr fr, W,4/Alj City/State/Zip /1)u)(b Policv # or Self-ins. Lic #4?zDEr78t3tZ Expiration Date Z Attach a copy of the 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 lcad to the imposition ofcrinrinal 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 ofthis statement may be forwarded to the O{fice of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the s and penalties of perjury that the information pruvided above is true and correct. Si t-(?ZT Phone# 5)9-3bZ-4,3f -5A'74D-3bz/z/ Olficial use only, Do not write i this area, to be completed by ciry or town official. Permit/License # Phonc #: 3.! City/Town Clerk 4. ELicensing Board Issuing Authoritv (check one): llBoard of Health 2.E Building Department5[ Selectmen's Omce 6. Eother Contact Person: www.mass.gov/dia i Business Type (required): 5. ! Retail 6. ! Restauranttsar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, elc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing I I frHealth Care l2.E orhe. - Citv or Town: Information and Instructions Massachusetts General Laws chapter I52 rcquircs all cmployers to provide workers' compensation for their employees. ; Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, express or implied, oral or written." An employer rs detined as "an individual. partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the receiver or trustec ofan individual, partnership, association or other lcgal entity, employing employees. However, the owner of a dwelling house having not more lhan 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 the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or rencwal of a license or permit to operate a busincss or to construct buildings in the commonwealth for any applicant who has not produced acceptablc evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, g25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract fo, thc performance ofpublic work until acceptable evidencc ofcompliance with the insurance requircments of this chapter have been prcscnted to the contracting authorily." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your siruation 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 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 coveragc. Also be sure to sign and date the.mdavit. The affidavit should be returned 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 questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the numbcr listed below. Self-insured companies should enter their sclf-insurance license number on the appropriate line. City or Town Oflicials Please be sure that thc afTidavit is complete and printed legibly. Thc Depanment has provided a space at the bottom of the affidavit for you to fill out in the evcnt the Office of Invcstigations Ins 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 multiple permirlicense applications in any given year, necd only submit one affidavit indicating current policy information (if necessary). A copy of the afldavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid aflidavit is on file for future permits or licenses. A new affidavit must be filled out each 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 pemrit to bum leavcs etc. ) said pcrson is NOT requircd to complete this affidavit. The OIIice 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. MA02111-1750 Tel. (857) 321-7406 or l-S77-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 www.mass'gov/dia Ao'CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A ]JIATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER, THIS :RTIFICATE DOES NOT AFFIRi'ATTVELY OR NEGATIVELY AilIEND, EXTEND OR ALIER THE COVERAGE AFFOROED BY THE POLICIES LOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 20443 24421 10494 35289 COVERAGES CERTIFICATE NUMBER NYC{0q808102.38 REvlsloN NUMBER: 6 ,i,,l DATE ( X/DOTTYYY} 1.1DU2021 PioorrcER MARSH USA, LLC, 1 166 A',!flle ot ltE Arrslcas New Yorl( NY 100:'6 ,rltt: thiltEare.LrDunlscss@maIstlcom Fax: 212 91&1307 Healtkare Team 948.1307 INSI,IRER A l ble orns ebe orsedndREDhaveINSUITIONALsmustADOprovlsiohoislderatTtoADDINNALUREDpollcy(lo )onstatementmenendorset.aulronncertalcteslhereqsuctth6torm3tedanndcon3itloofpollmaypolicy cNr0l 36965-STND-GAWP-24-25 h€allkare,accounlscss@,naEh.com INSU AFFORDII.IG COVERAGE to the csrtllicats holdor ln ll€u of such on HOID N/A GWP II{PORTANT: f tho corllflcalo If SUBROGAYION IS WATVED, thls cortficato doos not contsr ItISURER B NSURERC: Trensmdallon lnsurarce fu lr,lSURER 0 | Conllnenlal lnsurance C0. NST'RER E IIIIIURED FRESENIUS MEDICAL CARE HOI."DINGS, INC AND IHEIR SUESIDIARIES ANO DNISIONS 92OWITITER STREET WALTHAM, MA 02451-1457 D AI'IOMOBILC TIABIUIY CERTIFICATE HOLOER OWNED AIIIOS ONLY HIREo AUIOS ONI.Y SCHEOULEO AUIOSNONOWNEO AUTOS ONLY CANCELLATION CERTIF'CATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS. OTWITHSIANDICATED ER ODTHEFORlcYPOLABOVEMIIIEDEENBTOUEDETHINSUREDTHETtEsPOLICoNLISTEDSURANCEHABELOWVEISTHTlsCERTIFYoTHATHISHcTORESPECTDOCUMENTOROTHERCONDITIORoONCONTRACTTERMNDINGREMENTREOUIINTHTERMESSSBJUTOECTNEREIH TYPE OF INSURAI{CE 2,000,000$EACHOCCI]RRENCEx MEO EXP PERSONAL A AOV INJURY 1.000,000 3,000,000GENERAL AGGREGATE 2,000,000$PRODUCTS . COMP/OP AOGX a ccP2095784352 0Js) ccP2095781t83 (CANADA) ccP209s781365 (PR) 10i012021 10/01iD24 ro/fln024 COMIIERCLAL GEIIERAL LIABLTTY GEML AGGREGATE LMTT APPLIES PER: x Em fl CLAIMS-IJIADE OCCUR LOCPOLICY OTHER:i tSoDlLY liuUBY (P6lFlo) EOolLY ILURY (P.r accldon0 5 $ EACHOCCURqENCE AGGREGATE UIEAELLA L'AB E(CE3S LIAB OCCUR CIAlmS-MAOE oE0 Ex E,L. EACH ACCIDENI E,L- DISEiSE, EA ,2.000,000 l0/010025 10m12025 10/!12025 E L DISEASE - POIICY LIM'T wc2095784321 (0R, W) wc2ns784318 (CA) wc2095i81304 1001/2024 10,0112021 B C D woRt(ER:i ct rPEtlllaltor{ AND EXPLOYERA'IAEIUTY AI{YPROPRIETOR/PARINETVTNECUTIVE OFFICER/MEMBER EXCTUDED? oF oPERATICNS b.bi, N Y/N ll 1,000,000 3,m0,m0 r0i0r/2025 10i012025 PEROCCURRTNCE AGGREC{TE iM)]D021 1{I/D]n021 D PROFESSIONAL LIABILITY t ClCRPTloll Of oPER^llotlll / LoCATr,t{! /VEHCLES IACORI '10t, A&rdon l R.r!.rt Sct (!lL, ltEy !..!r.lrd r 'ftr. rp.c. L nfll..d) CERNFrcATE HOTOER ISA NAMED INSURED ON ATI. POUCIES LSTED ABOVE, .t I l CAPE CODARTIFIChI KIDNEY CENTER 211 WLLOW ST, YARMOUIHPORI trh 02675-171,1 SHOULOANY OF THE ABOVE DESCRIBED POLICIES BE CAI{CELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WLL BE DELIVERED IN ACCOROANCE WITH fiE POLICY PROVISIOI{S, AUIHORIZEO REPRESENTATIVE a"41 zzs'4 ' '€ ACORD 25 (20.t6/03) o r988-201 Th6 ACORD nsme and logo ars reglstered marks otAC I ACORO CORPORATION. All rights r€sorved. ORD t t I 2,000,000 10/01/2025 10/012025 10/01/2025 I I PER r 2,m,9. t 2,Cm.m ccPm95781352 (US) ccP209s784366 (PR) I",I