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Home My WebLink About2025-26Docusign Envelope ID: D3B23CEB-9EA9-44F8-9B13-CABBAD8E7AC7 afiitua LICENSI]bAlpt\-7q -\ FtlE: S I 50.00 /--> PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY rowN oF yARrvrourH B.ARD oF HEALTH <tr, Sirlj;l;:! 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION RECEIVED JUNE J0.2025 rrnr tn )nr( fuv^., Cc-r..<rPla-/dt" : ii LUi'rPI,EASE COMPLETE ALL QUESTIPNS NAME OF BUSINESS w U-( . BUSINESSTEL.* 45$9\S&as BUSINESS ADDRESS IN YARMOUTH Stanpn larmo,LtL-0ab(d-lu< MArLrNc eoonsss b1i h EMAIL ADDRESS id REQUI RED MANAGER/CONTACT PERSON TELEPHoNE * 6oK-A sK-1nq REQUIRED OWNER NAME lo 0 PO CORPORATION ADDRESS @ wNh Ltnbl {2{0a s Q^kr,Mft {l ln ort( rEL.# q0?Aq-0Q ( HoME ADDRESS l+bn4/e L-tnegln (Lt coRpoRAroNNAME(rFAppLIC esrl \olfu AlWfrl!fl ,uVlet * 4Al4lZ&S nLol 6 TAX ID (FL,IN oR SSN) REQUIRED o9 -ofi(Ew LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURN OF YOUR ESTABLISHMENT UNTTL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORN THE BOARD OF HEALTH MAY BE REQUIRED PRIOR l O REOPITNING. Town of Yarmouth taxes anq appropriately if paid: yes--Y1 liens must be paid prior to renewal or issuance of your permits. Please check no_ n/u_ MATLTNG aooness (049 v.,0.Jltr t\ltuuln 2L 5 Under Chapter 152, Sec.25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any Iicense or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofienewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Aflidavit. lfnot applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED v N ALL SAFETY DATA SHEETS ON FILE ANY NEW CHEMICALS MUST / RFNEWAL APPLICATION V BE PRE-APPROVED yN BY THE HEALTH DEPARTMENT. ON APPLICANT'S SIGNATURE DATE lo a5 PPLI The Commonweolth of Massoch usetls Dep ortmenl of In d uslri al Acci dent s Offtc e of In ve s I ig oti o ns Lofiyelte City Center 2 Avenue de Lafayette, Boston, MA 02lII-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant lnformation Plcase Print Leeibly E4sH dcBusiness/Organization Name:lat vL( Address:\\)Juhr for,r Lsvttotvt ,,t0{ oa({r(Phone #:qQ\4qT\qgCiWlStatelzip: Are you an employe r? Check the appropriate box: I am a employer with or pafl-time).* l. 2. 3. 4. employees (full and/ 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 ofexemption per c. 152, $ I (4), and we have no employees. fNo workers' comp. insurance requiredl** We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information*tlftie corporate officers have exempted themselves, but the corporation has other employees. a workers' compensation policy is required and such an oryardzation should check box # I . t1 e Health Careu. 12. I am an employer thal is providing workers'compensalion insurance for my employees. Below is the policy information. AInsurance Company Name: Insurer's Address:box Ll@oll?0 CitylStatelZip to lEaq Policy # or Self-ins. Lic. #wLqxar sqogl Expiration Date:r lrfqe Attacb a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A of MGL c. 'l 52 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 O{Iice of lnvestigations of the DIA for insurance verage verification I do herebl cerl and penulties of perjury that the information provided obove is true and coffect' [)ate:Si re qovq r the Phone #: Official use on\-. Do not i'ite in this areo, to be completed bl cit! or town ollicial' Department 3.[ City/Town Clerk 4'!Licensing Board Permit/License # Phone #: I 5 trBoard of Health 2.C guitoing Selectmen's Office 6. EOthcr Contact Person: Issuing AuthoritY (check one): City or Town: wvw.mass.gov/dia Buqif,ess Type (required): s.ARetail 6. I Restaurant/Bar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing Other 07to3t2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ,CERTIFICATE DOES 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), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: lI the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSUREO provisions or be endorsed. lf SUBROGATION lS WAIVEO, subject to the terms and conditions ol the policy, certain policies may require an endorsemenL A statement on this certificate does not confer rights to the certi{icate holder in lieu ofsuch endorsement(s). PRODT'CER The Hilb Group New England, LLC 2000 Chapel Mew Bkd Suite 240 Cranston Rl 02920 Kim Cabral, AAI,ACSR (800) 232-0582 (888) 5os 93oo kcabrel@hilbgroup.com INSURER(S) AFFORD'NG COVERAGE tNsuRERA, Utic€ National lnsurance Co ofTexas 43478 Colbea Enterprises LLC 695 Georce \.,tash ington H',!y Lncon Rt 02865-4257 tNsuRER E . Republic-Franklin lnsurance Co 12475 tNsuRERc. Utica Mutual lnsuEnce Co 25976 TNSLTRFR D . Beacon Mutual lnsurance Company 24017 CORD-CERTIFICATE OF LIABILITY INSURANCE COVERAGES cERTtF'CATENUMBER: c1246281952s REVISION NUMBER: THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED EELOWHAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOO INOICA-IED. NOTWTHSTANDINGAT.IY REOUIREMENT. TERM OR CONDITION OFAI.IY CONTRACT OR OTHER DOCUMENT WTH RESPECTTO vv}IICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO BY THE POLICIES OESCRIEED HEREIN IS SUBJECTTOALL THE TERMS. EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOW\ MAY HAVE BEEN REDIJCED BY PAIO CLA1IVIS, LIMITS EACH OCCURRENCE t 1,000,000 $ 100,000S r 5,000 PFRSONAI &ADV LN,]URY $ l,ooo,ooo GEN ERAL AGGREGATE r 3,ooo,oo0 PROOIJCIS , COMP/OPAGG $ 3,000,000 s 5653476 (Rl) 5653443 (NH&MA)a]ta1l2024 o7 to112025 COM M ERCIAL GENERAL TIABILITY GEN'LAGGREGATE LIMIT APPUES PER oTBER. Deduclble$10,000tr LOCJECT $ 1,000,000 SODILY INJURY (Per p€6on)s sBODILY ITUURY (Per actjd{r)07to1t2024 s s653526Bovl ED AUTOS ONLY HIRED AUTOSONLY sc|EDuL€D AUTOS NON OWIEO AUIOS ONLY AIJTOMOBILE UAAIUTY r 5,000,000EACH OCCURRENCE AreREOATE r 5,000,000 OCCUR ElcEss u a s 07tol/2024 07t41/2025c oEo RETENTTON a 10,000 E L EACH ACC OENT s 1,000,000 91,000,000E L O SEASE . EA EMPLOYEE oTto'12024 07101t2025 E L DISEASE. POLICYLIMIT r 1 000,000 89051 VIORXERS COMPENSAIION ANO EMPLOYERS UAAIUTY ANY PROPRIETOR/PARTNEF'EGCUNVE OFFICER/MEMAER qCLUOEO? OESCRIPTION OF OPERATIONS b6l 375,000a7 to112025 Lirnit5653528Garage Keepe6 Legal Llabllity B DESCRImON OF OPEFATIO|{S / LOCATTONS / VEHTCLES {ACORD 101, Addltlonrl Romarlit sch.dul., nry b. .tt Gh.d if n.E rPrc6 i3 cqulEd) \ b*ers Compensaton- MA & NH- Per Statue Polic!* I rc92912875905,4 EfreciveThD4-711125. Ljmits: '1,000,000/1 ,000,0000/1 ,000.000 Canier Aeonaut lnsurance Company CANCELLATIONCERTIFICATE HOLDER o 1988-20'15 ACORD CORPORATION SHOULD ANYOF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICEWLL BE DELIVEREO IN ACCOROANGE WITH THE POLICY PROVISIONS. AUTHORIZEO REPRESENTATI\E For lnf ormational Purposes ACORD 25 (20',l5/03)The ACORo name and logo are registered marks of AcORD All rights reserved. cr-arMeMADE E occuR 07 ta1no25 5653477 D TI]DfEUEtr rNsD I wvo