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I-ICENSE FEE S I50
TO\1'r'- OF YAR\IOUTH BOARD OF HEALTH
202512026 HANDLING.{\D STORAGE OF TOXIC OR HAZARDOUS NATERIALS
LICENSE APPLICATION
COMPLETE THIS APPLICATION A"\iD RETLTRN IT WITH
BY JUNE 30, 2025
LICENSE FEE
0[0 0 c' 'i 0'/\
NAME OF BUSINESS C BUSINESS TEL. +6?o
BUSINESS ADDRESS IN YARMoUTIT O 5 2 RaUtE 26 I,r,,T E gT YA R MO UT H M R O 2TT)
MAILING ADDRESS /n
E\{AIL ADDRESS
BEQLTRED, MANAGER/CONTACT PERSON I vrtliti
I'ELEPHONE T
BII}UBEII olYN ER n-AM E TEL.4 c;oS 'a16^ 367-<t
HOMI] ADDRESS oqL Rortt E o L,,;or-q,t lAAfioUaV il A o/)443
HEA TH DEPT
L
CORPORATION NAME (IF A}PLICABLE) TEL' +-
CORPORATION ADDRESS
L,J 0 A o +3MAILING ADDRESS L
OUIRED q t23 26L1
appropriately ifpaid: Yes-- no- n a-
under chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or ren-ewal of any
ha.n." o, p"rrit to operate a business ifa person or company does nol have a Certification of workers Compensation
inru.una". n, pun ofthe renewal or issuance ofyour permits, you must compl€te the erclosed Workers
TAX ID (FEIN OR SSN)RE
LICENSES RLN ANNUALLY FROM ruLY I TO JLNE 30. IT IS YOT]R RESPONSIBILITY TO RETURN
THE COMPLETED APPL]CATION(S) AND REQUIRED FEE(S)BY JLTNE 30. FAILUR.E TO DO SO WILL
RESUL T IN CLOSURE OF YOI.TE ESTABLISHMENT L]NTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S)ARE RECETVED. A HEART]{G BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PzuOR
TO REOPENING
Town of Yarmouth taxes and liens must be paid prior to renewaI or issuance of your permits. Please check
Com sation Affrdavit. lf not aPPlicable, pIease explain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED L-..-
YN
ALL SAFETY DATA SHEETS ON FILE \-."yN
ANYNEwCHEMICALSMUSTBEPRE-APPRoVEDBYTTIEHEALTHDEPARTMENT.
RENEWAL APPLICATION \../' NEW APPLICATION-
APPLICANT'S SIGNATURE DATE 2-)q,l o o25
,KHHil-B1qq3
PLEASf, COMPLf,TE ALL QUESTIONS
-$\The Commonwealth of Massachusetts
Department of Industrial Accidents
Ollic e of I nv e stig atio ns
I Congress Street, Suite 100
Boston, MA 02114-2017
*tow.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aoolicant Information Please Print Lesiblv
Business/Organization Name :a F CoR
Address: 252- Aot)rELS UF-qT \MOUTH IYl A o +va
City/StatelZip
Are you an employer? Check the approprirte box:
or part-time).*
2. I I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. inswance 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 *'orkers' comp. insurarce required]*
4. ! We are a non-profit organization, staffed by volunteers.
with no employees. fNo workers'comp. insurance req.]
Phone #:
tAny applicanr rhat checks box +i musr also frll out the section belo* showing their workers' cornpensatiorl policy informatioo.
*rlfthe corporare officeas hav€ erampted thenrselvcs, but rhe corporatioD has other employecs, a workers' compeosation policy is required and such an
organizatioD should chcck box #1
'nsation insurance for my employees. Below is the policy information.
a N1 I-^q An() P
I am tn employer
Insurance Compan
lnsurer's Address:o o
Ctry/SleleiZip
Policy # or Self-ins. Lic. #U B -? P,6B5S+9-'9-h - 142-- G Expiration Date tLloz/za2to
Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 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 ofthe DIA for inswance coverage verification.
I do hereby cenifu, u the pains and penalties of perjury that the i fomation proided above is true and coruecl
S ture
Phone #:
Date:
L1 '-gt
Phone #:Contact P€rson:
Permit/License #Cit-Y or Town:
wwu,.mass.gov dia
l-_ Prrt F"""
Business Type (required):
5. ! Retail
6. ! RestaurantrBar,/Eating Establishment
7. E Office ard/or Sales (incl. real estate, auto, etc.)
8. ! Non-profit
9. I Entertainment
10.! Manufacturing
I I .E Health Care
t2.E Other_
l. Eul am a employer with 9 employees (full and/
Ofticial use only. Do not b)ite in this uea, to be completed by city or town ofJicial
Issuing Authority (circle one):
l. Board of llealth 2. Building Department 3. City/Town Cterk 4. Licensing Board 5. Selectmen's OIfice6. Other