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Home My WebLink About2025-26n"N0 lLl0l fitllM-zs-lq€fLICENSE FEE $ I50 OT- \ ,\R}IOI;'f H BOARD OF HEAI,'tH 2 D STORAGE OF TOXIC OR HAZARDOUS LICENSE APPLICATION COMPLETE THIS APPLICATION AND Rf,TURN IT WITH THE LI BY JUNE 30, 2025 PLE,{SE CONIPLETE AI,L QUESTIONS 9 1916 !o1'^rr'r& $crel.. BUSINESS ADDRESS IN YARMOUTH ordn3t NSB.EAE n "'''E lifBiUThtr o#Ti MAILING ADDRESS €o-l ,/>EMAIL ADDRESS BEQIJ.IBED MANAGER/CONTACT PERSON RFOL;IRI]N OWNER NAME , (sV.- L TEL,#+{4{C] HOME ADDRESS CORPORATION NAME (IF APPLICABLE)(^0e C'oRPORATION ADDRESS + (Yl6\e.\ a1.-TEL. #5ok-1+S- r{1.1? o-16 MAILING ADDRESS I -u€ Jv-"^rt\ t-6 - \se51\31 LICENSES RUN ANNUALLY FROM ruLY I TO JITNE 30. IT IS YOIJR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LTNTIL 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 appropriatetyifpaid: Yes n0 Under Chapter 152, Sec. 25C. subsection 6.the Town of Yarmouth is required to hold issuance or renewal of any license or permt t to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As Pa.rt ofthe renewal or issuance ofyour perm its. you must complete th€ enclosed Workers leasc explain a nla- Compensation Affidavit. lf not aPPlicable, p REGISTRATION FORM SicNro eNn cotUPLETED ANY NEW CHEMICALS IIIUST BE PRE'APPROVED BY THE HEALTH DEPARTMENT' RENEWAL APPLICATION \'/NEW APPLICATION- r/ Yt. Y APPLICANT'S SIGNATURE {.*{ NAMEoFBUSINEss cqea t.rir4Jni-(+ rvt6+4 th( BUSINESSTaT +.4of-T4S- H(91 llP 11 Z0ilbwr I2512026 HANDLING A HEALTH DEPT TELEPHoNE # ++l+ -.I-ck- c\\a, \ TAX ID (FEIN OR SSN)BEIEIBSD CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE N N DATE. <\I.\Ti Applicant Information Please Print Lesiblv Business/Organization Name Address: ltS R-.tle- aSf . City/StatelZip:)Phone #:.5o:<- a1S - L\(11 Business Type (required): 5. ! Retail 6. E RestauranvBar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. E Non-profit 9. E Ent€rtainment 10.! Manufacturing I I .! Health Care r2!Elother /ho+el 6 Are you an employ€r? Check the appropriate bor: t. $-I am a employer with or part-time).* 2, E I am a sole proprietor or partnership and have no employees workiog for me in any capacity. fNo workers' comp. insurance required'l 3. D we are a corporation and its oflicers have exercised their right ofexemption 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 employees. [No workers' comp. insurance req.] employees (full and/ 'Any applicant that check box #l must also fill out the sectiotr below showhg their workers' compeNatiotr policy information.**If the corporate oflicers have exempted lhemselves, but the corporation has other employees, a worken' compensation policy is required and such ao organization should check box #1. I am tn employet thal is pro workers' compensalion insurance lor uy employees. Below is lhe polic)' informqtion. Insurance Company Name:e Y'l d n vl 6( Policy # or Self-ins. Lic. #Oo Explation Date o5\ar\a"a( Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration drte). Failure to secure coverage as required under $ 25A of MCL c. 152 can lead to the imposition of criminal penalties ofa fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of lnvestigations of the DIA for insurance coverage verification. I do hereby certdlt, under the pains nd penalties ofperjury thqt the information provided above is true srrd correcl S ture a. Phone#: ?+A -Q(f-'1 t01 OtJicial use only. Do nol wite in this area, lo be completed b)' cily or lown olJicial. Issui[g Authorit_v (check one): llBoard of Health 2.ElBuilding Department 3.! Ciry/Town Clerk 4.DLicensing Board Phone #: City or Town:Permit/License # 5E Selectmen's omce 6. Eother Contact Person: www'mass.gov/dia , rac Lurrarraurawcu,a,, ut tatussucr,uscaas Depaftmenl of Induslrial Accidents OlJic e of I nv estig atio n s Lafayette City Center 2 Avenue de Lafayetle, Boston, MA 021 lI-1750 www.mass.gov/dia Workers' Compensation Insurance Aflidavit: General Businesses lnsurer's Address; CitylStatelZip: lnlbrmation and lnstructions Massachusetts General Laws chapter 152 requires all employers to provide u'orkers' compensation for thcir employees Pursuant to this staiJtc, an employee is detined as "...every person in the scrvicc of another under any contract of hire, cxpress or implied. oral or written." At 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, pannership, association or other legal entity, employing employees. However, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house ofanoth€r who employs pcrsons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or pcrmit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable eyidence of compliance with the insurance coverage required." Additionally. MGL chaptcr 152. .s25617, t,u,"r 'Ncither the commonwealth nor any of its political subdivisions shall cnter into any contract for the performance ofpublic work until acceptable evidencc ofcompliance with the insurance requiremcnts ofthis chapter have been prcsented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your inswance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Ifan LLC or LLP does have employees, a policy is required. Be advised that this a{iidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign rnd date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department oflndustrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Depanment at the number tisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Olficials Please be sure that the aflidavit is complete and printed legibly. The Department has provided a space al the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. ln addition, an applicant that must submit multiple permiVlicense applications in any given year, need only submit one affidavit indicating curent policy information (ifnecessary). A copy ofthe affidavit that has been oflicially stamped or marked bythe city or town may be provided to the applicant as proof that a valid affidavit is on file for furure permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venhue (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of lnvesligations 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 and fax number: The Commonwealth of Massachusetts Department of Industria[ Accidents Office of Investigations Lafayene City Center 2 Avenue de Lafayette, Boston, MA02lll-1750 Tel. (857) 12l-7406 or l-877-MASSAFE Fax (617) 727-7749 orm Revised 7/2019 WWW.maSS.gOV/dia AcQo'CERTIFICATE OF LIABILITY INSURANCE HIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATIO N ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER. THISientncrtr ooes tor AFFtRMATtvELy oR irEGATtvELy AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN fHE ISSUING INSURER(S}, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER COVERAGES CERTIFICATE NUMAER RE\,SION NUMBER OATE (IX/DO/YYYYI 07nal2025 IiTPORTANT: lf lho c€rtiticate holdoi i! an ADDmONAL INSURED, the policy(ies) must lI SUBROGATION lS WAIVED, subjecl to the terhs and conditions o, tho policy, cenain policies may roqui,6 an ondorc6menl A stalemonl on this certilicate does not conter rights lo the cerlificate holder in lieu ol such endorsement(s). havo ADDITIONAL INSURED provlsions or be €ndorsod Ca.olyn Milano (800)64G1620 cmilano@hilbgroup-com IIISU RER(S) AFFOR DING COVERAGE The Hlb Group New ErEland. LLC MA 02601 973 lyannough Road Hyannls tNsuRER A. Lloyd's ot Lofldon N5uRERB - Evanston lnsurance Company 35378 tit_tuREF c. A$ocaled Employers lnsurance Co 11tO4Cape Winddft Motellnc.;Cape Windrift Molel Realty LLC 115 Routs 28 MA 02673 THIS IS TO CERTIF/ THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE POUCY PERIOD INDICAIED, NOTWIIHSTANDING ANY REOUIREMENI TERM OR CONDITION OFANY CONTRACI OR OTHER DOCUi.iENI WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANC E AFFOROEO AYTHE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ATT THE TERMS, EXCLUSIONSAND CONOITIONS OF SUCH POLICIES, TIMITS SHO\,YN MAY HAVE BEEN REDUCED BY PAIO CLAIMS 51,0o0,000 PREr',{SES (Ea Gurcne)5 50,000 MEO EIP lAnv one ffi), 5,000 PERSONA!A AOVINJI]RY s 1,000,000 GENERALAGGREGA'E 5 2,000,000 PRODTJCTS. COMP/OPAGG r lncluded COUMERCIAL GEIiERAL LIABILITY GEN LAGGREGAIE LIMIT AP Bli PD DED 500 lX,o" ffi o""u* xs2223816 03128t2025 43t28t2026 5 COMBINED SINGLE LIMI s BOOLY INJURY (P.r p.en)I BOULY IiUURY (Por a@dat)s $HIREO SCHEOULED NON{WNED AUTOUOAI!E LIABIL'TY sxEACH OCCURRENCE s 2.000,000 $ 2,000.000xUMAFEUAUAB EXCESS llAAts oao RETENTION I xo8w10304425 03t2812425 0312812026 oTlrx EL EACHACCIOENI $ 500.000 E,L OIS€AsE . EA EMPLOYEE 5 500,000C WOFXEiS COXPENItAT|OI| ANO Er'!PLOYERS' LlAEltlTY ANY PROPREIOR/PARINER,€XEC,IJIIIE OTfl CEFI/MEM8€R EXCLUDED? OESCFIPTION OF OPERAI]ONS bdoe wccs0050267562025A 03t28t2025 03128t2026 E.t_ olsEAsE - pou cY t_lMlT $ 500,000 DESCaTmO OF OPEiATIONS ' LOCATION9 / VEHICIES IACORD t 01, Addniond i.d.rtt 3.h.d{le. n , be .tt ched ii nor. tr... i. nqulrcd) -'Workers Comp€nsalion"' Tho ldlowing Omc€rs ar€ exduded ftom coverage: Ankit Palel; Shailssh Pateli thadresh Palel lnsurance coverage is limlted to the tems. conditions, exclusions, other lim tatlons, and endorsements. Nothing contalned in the Cerlillcate ol lnsurance shall bo d6em€d to hav€ altered, waived. orextended lho cove.ag€ pmvided by tho pollcf provisons CERIIFI H ER Soulh Yamoulh 1146 Roule 28 CAN toN MA 02664 @ 1988-2015 ACORD CORPORATION. All right! rororved. The ACORO name and logo are registered marks of ACORD SHOULD ANY OF IHEABOVE DESCRIBEO POLICIES AE CANCELLEO BEFORE THE EXPIRATION OATE THEREOE NOTICE WIIL BE DEUV€RED IN ACCORDA CE tvtrH rHE POUCY PROVISIOI{S. -..>- AU IHORIZEO REPRESEI,ITATIVE acoRD 25 (2016/03) I