HomeMy WebLinkAbout2025-26Ch tr /9 q7 BttHu-LS-P {L!LICITNSE
FEE: $150.00
TOWN OF YARMOUTH BOARD OF HEALTH
202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS
LICENSE APPLICATION
PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICEN
JUNE 30, 2025
PI,EASE COMPLITE AI,L QUESTIONS
rER[gG4 ZC25
H DEPT
NAME, OF BUSINF)SS ot0tA UL tl .(orni
BUSINESS TEL.#bO r-q6) ildr(
BUSTNESS ADDRESS rN yARMourH WE I\LJA S,f, l,,tti JqrtttatL, ml g4d/)
MArLrNGADDREss . gcrrrc 14 @-
I-]MAII- ADI)RF]SS 0 eot
REQI-IIRED MANACiEPJCONI'ACT' PERSON
CW\
Blu)resL Pa4
q
TELEPHoNE # k+h. I ff- cl Lq)
REQI-JIRED OWNER NAMF,rcl.* ]|Y'd|f.qbjt..-
HOMI] ADDRT]SS
CORPORA-IION NAME (IF APPLICABLE,)
a,ilL-,(
T'EL. #6 r.q -4ff
CORPOI{A.llON ADDRLSS H lv1 -6
MAILTNGADDREtI Srrrrz
9t- es<yo tt
I,ICENSES RI]N ANNUALI,Y FROM ruLY I TO JT]NE 30. IT IS YOUR RESPONSIBII,ITY TO RETURN
]]{E COMPLETED APPI-ICATION(S) AND REQUIRED FEE(S) BY JI.JNE 30. FAILL]RE I'O DO SO WILL
RESULTIN CLOSURE OF YOTIR ESTABLISHMENT LTNTII, TTIE RLQUIRED APPLICAI'IONS(S) AND
FEE(S) Azu] RI]CEIVED. A HEARING BEFORE TT{E BOARD OF TIEALTH MAY BE REQUIRED PzuOR
1'O REOPI-,NING.
Town of Yarmouth taxes an{ liens must be paid prior to renewal or issuance of your permits. Please check
appropriately ifpaid: yesP' no- nla-
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuancc 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 ofrenewal or issuance ofyour permits, you must complete lhe enclosed Worken Compensation
Afiidavit. Ifnot applicable, please cxplain:
REGISTRATION FORM SIGNED AND COMPI,ETED
CTIECK AND WORKERS COMP AFFIDAVIT ENCLOSET)
ALI, SAFE'IY DATA SIIEE'TS ON F'II-E
AI{YNEwCHEMICALSMUSTBEPRf,.APPRovEDBYTHEHEALTHDEPARTMENT.
I
RENEWAL AppLlcATIoN l,/ NEw APPLICA'IIoN-
A PPLICANT'S SIGNA IT-I'RE
N
N
l/YL/
Y
R.n'q
glnilral^k//4
€scpriito
l.
rlx rD (Fr-rrN oR ssN) REQUIRED
The Coamonwealth of Musachusans
Departnent o:F Industial Accidents
O;ffice of I nvesrtgations
I Coagress Slreet, Suitc 100
Boston, MA 021 14-2017
wtt at mass.gou/dia
Workers' Compensrtlon Insurance Affldevlt: Generel Businesses
BusinesVOrganization Name:b
A.I prnt rorm I
I
Address:+
Are you en emptoyer? Check thq rpproprlrte bor:
t. Etl am a employer with -( employees (full and,
or part-time).'
2. ! I am a sole proprietor or partnership and have no
anployees worting for me in any capacity.
[No workers' comp. insumnce requircd]
3. ! Wc arc a corpor.tion and its officers hgvc exercised
their right of exernpion per c. I 52, $ I (4), and we have
no employees, [No workers' conp. insurance rcquired]tr
4. ! We are a non-profit organizatiorL staffed by voluntecrs.
with no ernployecs. fNo workus' comp. insuancc rcq.]
City/State/zip:Phone #:'-h0& qq-3 (F1+/ae{f<tn3)
!193*;r"t*''*r'
6. E Resaurant/Bar/Eaaing Esublishmenr
?. I Ofrice andlor Salcs (incl. rcal csiatc, auto, elc.)
8. ! Non-profit
9. D Entcroinmenr
10.[ Menufacnring
t l.L] Hcalth Care
lz.E orhet
7
.Any opglic.Dr dl.t che.kr box ll mutr rlso 6ll out drc rEtito b?bs dtg{irg 0trii ro(lre'r' cottpcltsotiot plicy infomaiot...lf d!. c6.por8t offrc€r! havc cxcrprcd frclrsctvcs, but the caportln hs 0tt6 a4loyce., r *oriet!' colpa$rri@ poli"y is ruquird rad ilrch aa
q8&iati@ rtosld clrcl bor #1,
I atn an cmplclet rhal is
Insurance Company Name:
worlrcn'coapcasation iasuruacc lor ny cnploycc* Bclo* is the policy inforaatioa.
Ll,
fuw a2
lnsurer's Address:
Ciry/Sure/Zip:rt
Policy # or Sclf-ins. Lic. #{Expiration Date:
Att ch a copy ofthe 'compenr.tlon pollcy dechrerlon pege (showlng thc pollcy numbei rnd crpirrtion dste).
Failure to secure coverage as roquired under Soction 25A of MGL c. 152 can leed to ttrc inposition of criminal penalties of a
fine up to $ I ,5fi).00 and/or ure-year imprisonmort, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a &y against thc violator. Be advised that a copy of this statemant roay be forwarded to the Ofiice of
tnvcstigltions ofrhc DIA for insurance coveragc vcrification.
I do hereby cctti{y, uadcr tlc paias aad pcadtics olpcqiury lhel the inlonation pruvidcd abow is lrue and coffccl
Simature:l"il,aL k Date:a-H.15
{r o
Aficiol use oaly. Do aot wtiu ia this ena, a be cosplacd by city or towtt olficiol
Is3uing Authority (clrclc ooe):
L Borrdof Herlth 2, Bultding Dep.rtment 3. Clty/Town Chrk 4. llceosiEg Eornl 5. Selectmeo'r Ofilce
- Phcac #:-
Permlt/Llcenss #Clty or Town:
-
6. Other
WW*"OUr.gOv,'di:
I
aiQo'CERTIFIGATE OF LIABILIW INSURANCE
ABHIJAY CORPORATION O8A CAPE COD FARMS
88 CONSTANCEAVE
I.AiESTYARMOUTH
CERTIFICATE NUMBER REVISION t{UMgER:
oaTE ( il/oDrYYm
1111712025
LYRMATIMATTERICATE ALTEREGATIVELYMANVELY
CATEL.:CATE
ER.LO THISTEFICAHOETHERTIcHGUONFERSNRINONcoDONONOFNFOFISUlssEDTHCESRTIESOLICITHEPYBETHCOVERAGEORDENAMEXTENNo,ORFFRRTIETEFICAESooc E s UTHORIZEOANUIINGUsRTHENR(),ETWEEBTITUTECONTRACTNoEscOTSONUNSNRAEcDRTIFIoCETHISLOW.
R.EHOLDIHDcEERTIFIANoPROcUERTATIVENoERREPRES
GATI
ndorsedcssb.Us DREoDITILNANustmhaAD provrcsth.NAoL UNS RED pol cy(ants ODAtTthocartificatcldcrth.ItPOIM onmcntstatcAutcndorscmcnt.cniesnsitiothcmayrcqendndcypolstothcPolONtsubjc.tUBRO
this orrtifioai. do.s not conlcr to the clrtificate holder in lieu of suoh cndorsemcnt{s)
Carolyn Milano
(800) 640-1620
snrlano@hilbgroup.com
II{SU RER(S) A FFOROIITIG COVERAGE
31003lnsuiERA. Tri-State lnsuran@ Co of Minnesota
The Hilb Group New England. LLC
MA 02601
973 lyannough Road
Hyannis
25844tisuRER B . L,nion lnsurance Company
INSURERC
I SUR€R O
COVERAGES
THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE I
INDICATEO NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR O
NSURED NAMEDABOVE FOR THE POLICY PERIOO
THER OOCUMENIWTH RESPECTTO WI.iICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTA]N, THE INSURANCE AFFORDEO BY THE POL'CIES OESCRIBEO HEREIN IS SUBJECT TOALLTHE TERMS
EXCLUSiONSANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS
51,000,000EACHOCCURRENCE
300.000
s '10,000
1,000.000PERSONAL&ADVINJURY
5 2,000,000GENERALAG6RE6ATE
s 2,000.000PROOUCTS. COMP/OPAGG
12t16t2026A0v5574635-12
COM'IIERCIAL GENERAL LIABILITY
GEN'I AGGREGATE !]MII APPLIES PEREiff; E.*
OIHER
C SIIIGLE !LMIi
BoD LY INJIJRY lPer aco.lenl)
s
s
OW!ED
AU'TOS ONLY
HIREO
AUIOS ONLY
SCHEOULEO
AUTOS
NONOIINEO
AUTOS ONLY
AU'TOMOBILE LIABIUTY
s 1,000,000EACH OCCURRENCE
AGGFEGATE 1.000.000
OCCURU'IIBRELLA !]46
S
12t16t2A25 12t16t2026
CED
A0v5574635-12
OTH,
s 500,000E L EACHACCIOENT
$ 500,000E L DISEASE. EA EMPLOYEE
s 500,000E L DISEASE. POLCY LIMIT
12116t2A25 12t16t2426\ rcA5576594-12
woRxEFt! coLPEtl6aTtot{
AI'IO EI'PLOYERS' UABIUTY
ANY PROPRIEiOFYPARINER,EXECLJTIVE
OFFICER/MEMEEA EXCLUDEO?( .nd.tory h IH)
OESCR PTION OF OPERATIONS bEIOW
Y
oEscRtpnor oF opEiAtof,s / Locanoi! , vEHrclEs (acoRD tol, addtlond ii.m.t! sch.dul., mly b. .lt .h.d f nlor! .D.e It Equk d)
" Workers Comp lnformation "
Proprielors/Partne.s/Executive Ofi c€rsJMombers Excluded:
Harsh Patel. offcer
lnsuranc€ coverage is limited to the tems, conditions, exclusions, other limitations. and endorsements. Nothing contained in the Cenificate of lnsurance
shall be deem6d to havea,tered, waiv6d, or extended the coverago provided by the polic] provisions
1146 Route 28
Soulh Yarmoulh MA 02664
SHOULD ANY OF THE ABOVE DESCRIAED POLICIES BE CANCELLED BEFORE
THE EXPIRATIOI{ DATE THEREOF. NOTICE WILL BE DELIVEREO IX
ACCOROANCE WITH THE POLICY PROVISIOTS.
AU-T']ORIZED REPRESE'IIAIIVE
4--,-
FlCATE HOLDER Tto
O 1988-201SACORD CORPORATION. All rights rcs.rvrd
Thc ACORD n rnc and logc ara rcgistarcd m.rks of ACORDACORD 25 {2016/03)
AS AFFORDEONOT
oertaintarmswatvEo,I
CLA,MS-MADE ffi o""u"
12116t2425
s
BOOjLY INJURY (Pcr pefs)S
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