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Home My WebLink About2025-26'o TOWN OF YARI\IOUTH BOARD OF HEALTH 202st2026 HANDLTNG AND STORAGE OF TOXIC OR HAZARDOUS ryrrft'E qlAls rr, ?i LTcENSE APPLrcArroN S> SsnliliUCOMPLETE rHIs APPLICATIon* AND RETURN Ir WITH run ltctf,frfffr7iD BY JLr'NE 30, 2025 CL u[a[5 t LICENSE FEE $ I50 T+luM -ts- \tr 'l+ af,4.YgtlrP,t y 2n ?PLEASE COMPLETE ALL OTIESTIONS NAMEoFBUSTNESS C^ o GJ Tr'trcLanrrt Euur^urrrur.o7T CBUSINESS ADDRESS IN YARMOI.JTH MAILING ADDRESS EMAIL ADDRESS BLqII.BED MANAGER/CONTACT PERSON TELEPHoNE o fr?- l)f-ID L/ RT'OI,IRFD OWNER NAME TIOME ADDRESS o 0 TEL.#J.J CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TEL. # MAILING ADDRESS TAX ID (FEIN oR SSN) REOUIRED LICENSES RTIN ANNUALLY FROM ruLY I TO ruNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIOIT-(S) AND REQUIRED FEE(S) BY JLrNE 10. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOT]R ESTABLISHMENT LNTIL THE REQUIRED APPLICATIONS(S)AND FEE(S) ARE RECEIVED. A HEARING 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 of your permits. Please check appropriately ifpaid: yes-f no- nla- Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compe nsation Aflidavit. Ifnot applicable, pleasc cxplain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE N A\}' NE\1'CHEMICALS }IUST BE PRE-,{PPROVED BY THE HEALTH DEP,{RTMET'T. D( YK Y RENEWAL APPLICATION APPLICANT'S SIGNATURE NEW AP CA N DATE J N The Commonweolth of Massachusetts Department of Industial Accidents OfJice of I nvesti g atio n s Lalayette Ciry Center 2 Avenue de Lafayette, Boston, MA 021I I -1750 www,mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: City/State/Zip Phone #: *Any applicant thal checks box # I musl also fill out lhe section below showing their workers' compensation policy information.**lfthe corporate officerc have exempted themselves, but the corporation has other employees. a workers compensation policy is required andsuch an organization should check box #1. s--l I am a sole proprietor or partnership and have no employees working for mc in any capacity. INo workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right of exemption per c. 152,$l(4),andwehave no employees. [No workers' comp. insurance required]* +.! We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] a propriate box: 2E Are you an emploverl Check the employees (full and/ or part-time). * t.@ I am a employer with Business Type (required): 5. ! Retail 6. ! Restaurant,Bar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, elc.) 8. ! Non-profit 12.@ other eoh _\k t\ c l t.a1 9. l0 ll Entertaiffnenl Manufacturing Health Care I am an employet lh lnsurance Company Insurer's Address at is providing worhers' compensolion insurunce for my employees, Below is the polic5, informotion. Name: Afl,.aofl c C,l"a,l+gt- TNSu/ft/)( e Qor-oa.t vt--TI ciryi stateizip: Policy # or Sel Attach a copy WC 76 @ f-ins. Lic. #Expiration Date of the workers' compcnsation policv declaration page (showing the policy numbe nd e iration date). Failure to secure coverage as required under $ 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 upto $250.00 a day against the violator. Be advised that a copy of this statemenl may be forwarded to the Office of Investigations of the DIA for insurance coverage veriflrcation. r dc Ph ins andpcnalties of perjury thst the information proyided oboye is true and correct. Dat -r Ollicial use onll', Do not write i this srea, to be .ompleted by r:igt or town official. Citv or Town: permit/License # lssuing Authority (check one): t [Board of Heatrh 2.E Buitding5fl Selectmen's Offtce 6. Eoth€r Contact Person: I)epartnrent 3.E City/Town Clerk 4.EILicensing Board Phone #: wll/w.ftass.govldia Applicant lnformation Plcasc Print Legiblv ( I do hereby I Information and Instructions Massachusetts Gencral Laws chapter 152 requires all employers to provide workcrs' compensation for lheir employees. .- Pursuant to this statute, an employea is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written." An employer is deflrned as "an individual, partnership. association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise. and including the legal representatives ofa deceased employer, or the receiver or trustee ofan individual, partnership, association or othcr legal cntity, employing cmployees. However, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe 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 cmployment be deemed to be an employer." MGL chapter 152, g25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a licensc or permil to op€rate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with thc insurance coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pcrformance ofpublic work until acceptable cvidence ofcompliance with the insurance requircrrrents of this chapter havc hccn pre:;,:n1cd to tl!e conlractillg autlrority." Applicants Please lill out the workers' compensation a{fidavit completely, by checking the boxes that apply to your situation and, il 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 membcrs or partners, are not required to carry workers' compensation insurance. If an 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 coverage. Also be sure to sign and dat€ the affidavit. Thc affidavit should be rehrmed to the city or town that the application for the permit or license is being requested. not the Department oflndustnal Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Deparlment at the number listcd below. Self-insured companics should entcr thcir self-insurance license number on the appropriate line. City or Town Officials Plcase be sure that the affidavit is complete and printed legibly. Thc Departmenl has providcd a space at the bottom of the affidavit for you to fill out in thc event the OIIce of lnvcstigations has to contacl you regarding thc 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 submil multiple permit/liccnse applications in any given ycar, need only submit one affidavit indicating current policy information (ifnecessary). A copy ofthe affidavit that has becn officially stamped or marked by the city or town may be provided to the appticant as proofthat a valid affidavit is on file for future permits or licenses. A nerv affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit nol relaled to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this aflidavit. The Offrce 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 Til3b:}[l:"*earth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette CitY Center 2 Avenue de LafaYette, Boston, MA 021I l-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 Form Revised ?/2019 www'mass'gov/dia eiQo' 6116t2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER. THIS CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLOER. IMPORTANT: lf ths cortlflcate holdor i3 an AOOITIONAL INSURE0, th6 policy(ies) mu3t havo ADOITIONAL INSUREO provisiod. or be endorsed. It SUBROGATION lS WAIVEO, subject to the terms and condition. of the pollcy, cerlaln pollci.6 may rcquire an .ndoraomont, A atatemont on this certilicate does not confor rlght6 to th6 cortificato holdor in lisu of.uch endoraemont(s). PROOUCER Rogerscray, A Baldwin Risk Partner 410 University Ave Westwood MA 02090 PHONE 800-553-1801 877-816-2156 mal .com !NSIJ AFFORDING COVERAGE tNsuRERA: selective lnsurance co of soul 19259 NtuR€o Cape Cod lnsulation, lnc. 18 Reardon Circle South Yarmouth MA 02664 caPEcoG2T rr{suRER 8: Selective lnsurance Com ol 12572 tNsuRER c: Atlantic charter lnsu.ance com 44326 rNsuREROr crum & FOrSter cial lnsur 44520 INSURER E IN COVERAGES CERTIFICATE NUMaER: 227156849 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONOITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS, EACHOCCURRENCE s1.000 000 s 15 000 $500,000 MEO EXP PERSONAL & AOV]NJURY GEN ERA! AGGREGATE PROOUCTS , COMP/OP AGG s2 000 000 s 2,000 000 $ 1,000,000 5 613A12025s 2513647X x COi/IMERCIAL GENERAL L|AAILIIY GEN'L AGGREGATE LIMIT APPLIES PER x OT CLAIMS.MADE OCCUR POLICY LOCf--l pno f--.lLl JECr L,l BODILY INJURY (P.. FEor) BODILY INJURY (Po. accid€.1) Xx 5l3A/2A21 6/30/2025 S $ AUTOS ONIY HIREO AUTOS ONLY A 9109191B f, AUTOMOBILE LIABILITY SCHEOULEO AUTOSNONO!!NEO AUTOS ONLY EACH OCCURRENCEx 000 000 $ 2,000 000 AGGREGATE U SRELLA LIAB EXCESS LIAB OCCUR CLAIMS.MADE 6t30t2021 613012025 OED RETENTION s 2513647 X € L. EACH ACCIOENI 11,000,000 E L, OISEASE. EA EM WORKERS COXPEIISATION AND Ef PLOYERA' U BILITY ANYPROPRIETOR/PAFTN ER/EXECUTIVE OFFICER/I'EMEEREXCLUOEO?N \ rc100136905 DEscR,PTloNoFoPERATro 613012024 613012025 E,I, OISEASE. POLICY LIMIT s1 000 000 s1,000,000 $1 000 000 s1,000,c00 t20,000 1112t2021 't'1t212025 OESCRIPTION OF OPCRA'IOIS / LOCAnON! /VEHICLES (ACORO i Ol, Addldon.l R.mlrt. Sch.dut., m.y b..ti.ch.d li mor..p.cr l. (qUnd) \rvhen Requhed by V\,/ritten Conlracl the Following Applies:General Liability - Addltional lnsured Onqoiflg (CG 73 00 i0i23) and Compteted Operalion (CG Z9 88 1O/23) primary and Noft,Contrtbutory Bas,s (CG 73 OO10/23). Waiver-of Subrogatron (CG 73 Od'10/ri)Aulomobile - Addilional lnsured, Pnmary and Non-Contributory Basis. Waiver of Subrogation (CA 7g 09 Ozt 24)Workers Compensalion - Waiver ol Subrooation (Wc 00 03 13 0,{ 84) Excess/umbrella - Additlonal insured follois form over underlying Gdneral Llability and Automobile Liability, Additional lnsured primary and Non-ConlflbutoryBasis (CXL 449 06 17) CERTIFICATE HOLDER CANCELLATION S}IOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLEO BEFORErXE EXPIRATIOT{ OATE TIIEREOF, }IOTICE WLL BE OELIVERED INACCOROANCEWITH THEPOLICYPROVISIONS,Town of Yarmouth Health DeDartment1'146 Route 28 South Yarmouth MA 02564 @ 1988-2015 ACORD CORP The ACORO namo and logo are reglstqred marks of ACORD ORATION. Att rtghts roservee CERTIFICATE OF LIABILITY INSURANCE i..n<.1 Pa-q1106, 6n4t2021 S a 1.000.000 s X c cPL-116195 ACORD 25 (2016/03)