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ARD OF HEALTH
2025/2026 IL{NDLING AND STORA xIC OR HAZAR"DOUS I\tr{TERIALS
LICENSE APPLICATION
COMPLETE THIS ATPLICATION AND R-ETIJRN IT WTTH THE LICENSE FEE
BY JUNE 30, 2025
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NAME OF BUSINESS
BUSINESS ADDRESS
MAILING ADDRESS
usntess rcr. * so?' ??f, ' 3 ?5 5
INYARMO V)
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EMAIL ADDRESS
ar: a ) i : :{ ij i) }TANAGETV CONTACT PERSON
TELIPHONE #t6?-7?L - 3p {
Rl:.OI. I -q:.'i) OWNER NAME TEL.4 ?I 0
uoueepnnEss J
APPLICABLE)a,C a
I
o o)ry
CORPORATION NAME UF
CORPORATION ADDRESS
MAILING ADDRESS
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TAX ID (FEIN OR SSN}:rRED o4' ))oZ t. oD
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LICENSES RUN ANNUALLY FROM JIJLY I TO JUNE 30. IT IS YOL'R RESPONSIBILITY TO RETURN
THE COMPLETED A}PLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESIJLT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQI.IIRED A?PLICAT]ONS(S) AND
FEE(S) AITE RECE
TO REOPEN]NG.
IVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PzuOR
Town of Yarmouth iaxes and licns must be to renewal or issuance of your permits. Please check
appropriately ifpaid: yes- no--
Under Chapter 152, Sec. 25C, subsection 6 of Yarmouth is requircd to hold issuance or renewal of anyo\r'n
hcense or permit to operate a business ifa Person or company does not have a Certification of Workers Compensatron
insurancc. As part ofthe renewal or issuance ofyour permits, you must completc the erclosed Workers
applicable, Dlease explainCompetrsetion AI[drYit. If not
RTGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORK.ERS COMP AIFIDAVTT ENCLOSED
ALL SAFETY DATA SHEETS ON FILE
ANY ITIEW CHEMICALS MUST BE PRE.APPROVED BY TIIE I{EALTII DEPARTMENT'
JL
Yx
Y
N
N
APPLICANT'S SIGNATURE DATE:
PLEASE COMPLETE ALL OUESIIONS
RENEWAL APPLI'O'O'U T NEW APPLICATION-
f\.The Commonwealth of Massachuseas
Department ol Induslrial Accidents
Ofice of Investigations
Lafayme City Center
2 Avenue de Lafoyate, Boston, MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Ad&ess:
City/State/Zip:H
e c4
Phone #:rto --/ ?Dn
Busincs lype (requlred):
5. D Retail
6. I Restaurant/BarlEating Establisbmctrt
7. E Office and,ior Sales (incl. resl estate, auto, etc.)
8. Ell Non-profit
9. ! Entertainment
lO.f] Manufacnrring
I l.El Health Carc
A
.Any applicarl th.t ch.cks box #l must also fill out the section below showi[g their worksrs' coqrprnsation policy information.r+lfthe coryorala ofncer havc ex.mpted themselvcs, but Oe corporstion har othcr cmployccs, a worka6' compeoietion Policy is rcquk d and such an
or$nizalion should chccli box #l.
I am an employer thot k providing *o*ers' compentation insumnce fot my employecs. Below is lhe policy inforaution-
lnsuance Company Name:-tol4't n < arr
Insurer's Address:,B
city/shte/zip:a a bol
Policy # or Self-ins. Lic. # Expimtion Date:-
Attsch a copy of the workers' compensstion policy declarrtion prge (showitrg the policy number rnd explrrtion date).
Failurc to seowc coverage as required undcr $ 25A ofMGL c. 152 can lead to the imposition of crimin l penalties ofa frne up
to $1,500.00 and/or one-year imprisonment, as well as civi-l 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 of
the DIA for insurance coverage verification.
I do hereby certify, u the ry that the inlormation provided above is trae correcL
Da 2 26-
Phono #: 5OP . 1aU'3P{ <
Are you an employer? Check the rppropriate bor:
t . E t o, a employer with 7 OO A employees (full and./
or part-time).r
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 of exeoption per c. 152, $ l(4), and we have
no employees. [No workers' comp. insurance required]'
4. ! We are a non-profit organization, staffed by volunteers,
with no ernployees. [No workers' comp. insurance req.]
2.
3.
Official use only. Do not write in this aree, to be compltted by city or town ofiicial
Issuing Authority (check ooe):
t f]Bo=ard of Heatth 2E Buflding DepartDent 3I]Ciry/Towu Clcrk 4.!Licensing Board
Phone #:
City or Town:P€rmit/LlceDs€ #
5E Selectmen's Office 5, Eother
Contact Person:
www. Iles3. gov/dia
Aoolicant Informrtion Please Print Legiblv
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