HomeMy WebLinkAbout2025-26LICENSE FEE $ 150 -15
TOWN OF YARMOT-ITH BOARD OF ITEALTH
202sl2026 EANDL^. *, fl8*srriili#i8i nAzARDous MArBnursRECEi
VE n
COMPLETE TEIS APPLTCATION A}ID RETTJRN IT WITE TIIE LICENSE FEE
BYJIJNE30,2025 ,t.l
PLEASE COMPLETE ALL OI'ESTIONS HEA(IH OEP
CP 9\q['lwp- a
I
Charr Custom Boat ComPanY, LLC USINESS TEL. #
BUSINESS ADDRESS IN YARMO 20 Corporation Road
MAILINc ADDRESS same
EMAIL ADDRESS jean.chancustomboats@gmail.com
508-375-0028NAME OF BUSINESS
CAIIIIED
Jean M BurnsBEOIM,ED MANAGER,/CONTACT PERSON
TELEPHONE #508-375-0028
508-776-6373
BEOI]IBED OWNERNAME TEL.#
HOME ADDRESS 26 Cotuit Bay Drive, Cotuit, MI
CORPORATION NAME (tF A}PLICABLE)TEL. #
CORPORATION ADDRESS
MAILING ADDRESS
37-1476725rAxrD (FErN oR SSNIBEQUIEED
TI{E COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILIIRE TO DO SO WILL
RESULT IN CLOSURE OF YOIIR ESTABLISHMENT IINTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECETVED. A HEARING BEFORE THE BOARD OF HEALTTI MAY BE REQUIRED PRIOR
LICENSES RUN ANNUALLY FROM JI'LY I TO JLINE 30. IT IS YOIJR RESPONSIBILITY TO RETI.IRN
TO REOPENING
Tov,m of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour pemits. Please che{k
Compensetion Afiidavit.If not appli please cxplain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AIFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ON FILE
YN
ANY NEW CEEMICALS MUST BE PRE-APPROYED BY TIIE ENALTE DEPARTMENT,
RENEWAL APPLICATION NEWAPPLICATION
appropriately ifpaid, y""y' no- n/a
Under Chapter 1 52, Scc. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any
licelse or permit to op€rate a business ifa p€rson or company does not have a Certification of Workers Compensation
insurance. As part ofthe renewal or issuance ofyour permits, you must comPlete the enclosed Workers
N
Robert Bodurtha
AppLrcANlssrcN on u'r€aderrt Fat "b{a, DN:E 6t12t2o2s
The Commonwealth of Massachusets
Depart nent of Industrial Accidents
Olftce of I nvestigations
Lafayette CiO Center
2 Avenue de Lafayefle, Boston, MA 02III-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Narne: Charr Custom Boat Company, LLC
Address: 20 Corporation Road
,?)
CitylStatelZip; Yarmouth Port, MA 02675
Are you an employer? Check the ate box:
L El I am a employer with employees (full and/
or pan-time).+
2.[ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance requircd]
3. I We are a corporation and its officers have exercised
their right of exemption per c. 152, $ I (4), and we have
no employees. [No workcrs' comp. insurance required]r{
4. ! We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' cornp. inswance req.]
Buslness Type (required):
5. E Retail
6. fl RastaurantrBar/Eatlng Estabtshment
z. ! Office and/or Sales (incl. real estate, auto, etc.)
8. ! Non-profit
9. I Entertairnent
l0.fl Manufacturing
I I.[ Healttr Care
t2.g other Marine Service
rA[y applicant thEt chccks box #l murt also lill out lhc scction below showing thcir workers' compa$ation policy informatiott.*.lfth. corpontc ofrc.fs blvc cxct[ptcd th@salvcs, but thc corporation ha! oficr arnployc6, s r,rotkcrs' compcosation policy i! rcquirad and such an
orgDization should chcck box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the poliqt information.
Name: Maritime Proqram Grp
Insurer's Address: P.O. Box 25250
CitylStzrelZip Lehigh Valley, PA 18002
Policy # or Self-ins. Lic. #202401-08-11-76-0y ExpiBtion Date:9-14-2025
S
lhatthc info iation provided above is t?ue a d conccl
oate 611212025
Phone #: 508-375-0028
Oficial use only. Do not i'rite h this arca, to be cornpleted by city or tob'n ofrtciat
Issuing Authority (check one):
I flBoard of Health 2.! Bulldtng Department 3I] City/Town Clerk
Permit/License #
4. ElLicensing Board
Phone #:Contact Person:
5E Selectmen's Olnce 6. Eother
wwumass.gov/dta
A.oplicant Information Please Print Lesiblv
6,
Phone #: 508-375-0028
lnsurance Company
Attrch r copy ofthe workers' compensation policy declaretion pege (showlng the policy number and expiration date).
Failure to secr:re 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 imprisonoent, as well as civil penalties in thc form of a STOP WORK ORDER and a fine of up to
$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of
the DIA for insurance coverage verification.
I do hereby under the snd
City or Town: _