HomeMy WebLinkAbout2025-26JUL 1'4 ?0?5
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HEALTH TDE
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LrcENsE FEE $r5 o BHttM' z 3 -E/b
2025/202 .{N
OF YAR]VIOUTH BOARD OF HEALTH
D STORAGE OF TOX]C OR I{AZARDOUS MATERIALS
LICENSE APPLICATION
COIVIPLETE THIS APPLICATION AND RETURN IT rvITH THE LICENSE FEEBY JUNE 30, 2025
NAME OF BUSINESS u I
BUSINESS ADDRESS IN YARMOUTH 1
MAILING ADDRESS
EMAIL ADDRESS
R]E O_LTR I D MANAGER/CONTACT PERS ON
TELEPHONE #{
B{OIIq[D OWNERNAME
gonraopnsss 3
CORPORATION NAME (tr A.PPLICABLE)4
coRPoRATroN ADoa,ess P8
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BUSINESS IEL, #
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TEL,#
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MAILINGADDRES
rAx rD (FErN oR ssN)&EOLIRID o4' 2to 3u oa
appropriatcly ifpaid: yes_ no_
UDder Chapter I52, Sec. 25C, subsection Town of Yarmouth is required to hold issuance or renewal ofanylicense or permit to operate a busiucss ifa perso11 or company does aot have a Certification of Workers Compeosahon
insurance. As pan ofthc renewal or issuance ofyourpermits, you must complete the eDclos€d Workers
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""ENS'SRUNOM'IUTTIE COMPLEIED A}PLICATION(S) AND REQURED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESULT IN CLOSURE OF YOIIR ESTABLISHMENT UNTtr. THE REQUIRED A?PLICATIONS(S) AND
FEE(S) Ag5 P36PWED, A TIEARING BEFOR.E TIIE BOARD OF HEAITH MAY BE REQINRED PzuORTO REOPENING.
Co ation Alfridayit. Ifuot Licable ease
REGISTRATION FORM SIGNED AND COMPLETED
C}IECK AND WORKERS COMP AFFIDAVITENCLOSED
ALL SA.FEry DATA SHEETS ON FILE
NAIry NEW CHEMICAI,S MUST BE PRE.APPROVED BY TEE EEAI,TII DEPARTMENT.
RTNEWAL APPLICATION
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APPLICANT'S SIGNA
NEW APPLICATION
PLE.{SE CO}IPLETE ..lIL OLTSIIOTS
5A<)- ryll- - 30
to renewal or issualce ofyour permits. Please check
,on, t lz lzd-
The Commonweahh of Massachusetts
Departmeat of Industrial Accldmts
Ofice of Investigations
Lalqene City Ceater
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gou/dia
Workers' Compensation Insurance AIIidavit: General Businesses
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Business/Organization Name:
Address
Ciry/SratelZip H
c4
Phone #: .f/P.-)DA
Busitress Type (required):
Retail
Restaurany'B arlEating Esablisbmeot
I Omce and/or Sales (incl. real estate, auto, etc.)
8. fi Non-profit
9. fl Entertainment
10.! Manufacturing
I I .ffi Health Care
'Any applicant $at chccts box #t mult also 6ll out rhc r.cion bclow shoving lheii workers' compcasation policy information.
"lf thc corpodte officcrs hav. cxempEd th.rnselves, bu! thc corporarior has other employc.cs, a work€'r' compenssdon policy is rcquired and such an
orFnization should ch€ck box #1.
I aa an emplqter that is Providhg workcrs' compensation insurunce for my eaployccs Be low k he poliqt hlormation
Ilswance Company Namc: -lz )l - tn < ortr
5
6
7
Are you rn employer? Check the appropriatc bor:
I . ! I am a emplo yet witl '? Oo o employees (tutl andr
_ [No workers' comp. insuraocc requted]
3. Ll Wc are a corporation and its officers have exercised
their right of exeuption per c. 152, $ I (4), and we have
_ no employees. [No worken'comp. insurance required]t
+. ! We ue a non-profit organization, staffed by volunteers,
or part-timc).*
I am a sole propriclor or partership ard haye no
employees working for me in any capacity.
with oo employees- [No workers' comp. insurance
2.4
req.l
aInsurer's Address:
o o{
Policy # or Self-ins. Lic. # Expiration Date:_
Attrch s copy of the workers' compensetlon policy declrration pegc (showlng the policy number end expiration dst€).
Failure to secure coverage as required under $ 25A ofMGL c. 152 can lead o the unposition of criminal pcnalties ofa lme up
to 31,500.00 and/or one-year imprisonment, as \rcU as civil penalties in thc form of a STOP WORK ORDER ad a 6ne of up to
E250.00 a day against the violator. Be advised that a copy ofthis statement may be forwatded to the Office oflnvestigations of
the DIA for insurance coycrag€ verificalion.
I do hereby certify,and penakies of perjury that rte information ptovlded abovc it tue and conecl
Phone #: f6 {? -'7'7L' 5 P S
Officitl use only, Do not trrite id this area, to be co ple,e,l b! cit), ot ,ou/n ofrcisl
City or Town: _ pcrnit/License #
Isluing Authority (checl one):
l.EBorrd of .Eerlth 2.EIBuilding
5E Selectnen's Olnce 6, EOther
Contact Person:
D€p8rtment 3,8 Ctty/fown Clerk 4.Dlicenstng Boerd
Phone #:
ww. ma.rs.gov/dia
Applicant Jnformation Please print Leqiblv
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