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Home My WebLink About2025-26TOWN OF YAR}IOUTH BOARD OF HEALTH 202512026 HA,\.,DLING ,{-\D STOR.IGE OF TOXIC OR HAZARAQLIS M,\TERIALS LrcENsE APPLTcATToN h'En' ' COMPLETE THIS APPLICATION AND RETURN IT \I'ITH THE LICENSE FEE BY JtrNE -10. 2025 clc loo a + I-ICENSI-] FEE S I5OrilH U a3-tlt7 6arar: PI,EASE CoI\IPLETE AI,L OUI'STIONS HEALTH I BUSTNESSTEL. # ;o8- 7 7 S OT rS' (-t)u ,L-(t t..i OL(D NAMEoFBUSINESS CLo''" /L'o (ectr BUSINESS ADDRESS IN YARMOUTH / I a MAILING ADDRESS EMAIL ADDRESS / NFo € C6iop t^L 4< f<-31-e> cq-T . /* BI]OU.IBED MANAGEPJCONTACT PERSON TELEPHoNE# f,o8--11f^ ctq >T I z-a BE]OIJIBIDOIVNER NAME TEL.# HOME ADDR.ESS CORPORATION NAME (IF APPLICABLE)(oLou,oL /xrut A.so<.rEL.# Sbg'11g-o?)f Srrq^i d r s l/OCORPORATION ADDRESS I(a4-A a. MAILING ADDRESS J r-,'. .c- TAx ID (FEIN on SSNIBE@IBED 6q-1Et gr1\ LICENSES RI.N ANNUALLY FROM JULY I TO JL]NE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLTSHMENT LNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A TIEARING BEFORE THE BOARD OF HEALTH MAY BE REQU]RED PRIOR TO REOPENING. Town of Yamrouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check annronriatelv if oaid: ves no n a 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 Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compen sation Affidavit. [f not applicablc, plcase explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKTRS COMP AFFIDAVIT ENCLOSED *.. YN ALL SAFETY DATA SHEETS ON FILE N ANY NEW CHEMICALS MUST BE PRf,.APPROVED BY THE HEALTH DEPARTMENT. APPLICANT'S SIGNATURE NEW APPLICATION-RENEWAL APPL'CO''O* X s67e. <"/rtkorf i--The Commonwealth of Massochusetts D epartm ent of In du stria I Accide n ts Olftce of Investigations Lafayette CiE Center 2 Avenue de Lafayette, Boston, MA 021I1-1750 www,.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name At .,- ,ot L<r.s Z*so {'Azs.,<, Address: City/State/Zip:o'b'|,/t Phone#: <d,-71f- o "rfBusiness Type (required): 5. ! netail 6. ! Restaurant, Bar/Eating Establishment 7. 8. 9. l0 ll t2 Office and/or Sales (incl. r€al estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care Other *Any applicant that checks box #l must also fill oul the section below showing the workers' compensalion policy information. +*lf the corporate officeas have exempted themselves. but the corpomtion has other employees, a workers' compensation policy is required and such an organization should check box #1. Are you an emplo.'-er? Check the appropriate box: 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 exemption per c. 152, $ I (4), and we have no employees. [No workers' comp. insurance required]+ We arc a non-profit organization, staffed by volunteers, with no employecs. [No workers' comp. insurance req.] 2 3 4 o employees (full and/t. EI I am a employer with or part-time).* I om an employer that is providing workers' compensolion insumnce for my employees, Below is the policy inlormotion. Insurance Company Nanre 4/ eli-€rJ C lnsurer's Address 7qn ,..c r"r/ 5f ' CityrState,Zip ,^2;2p..l: Br< I4D.0L{72o - oToo Policy # or Self-ins. Lic. #Aeg r ou11 02-Erpiration Date oi o/2.oz-Q Attach a copr- of the workers' compensation policy declaration page (showing the policy number and expiration date). Iailure to securc coverage as required undcr $ 25A ofMGL c. 152 cau lead to the imposition ofcrirninal penaltics of a 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 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 thc DIA for insurance coverage verification. I do hereby certifi,the pains and penalties of perjury thst lhe inform ion provided above is true and correcl' Si Date 57. I-qvt- iyG-\ 2{ Phone # O!ficial use onty. Do not b'rile i this area, to be completed by cit)' ot town ollicial' 5D Selectmen's Ofiice 6. Eother Permit/License # Phone #: 3.E City/Town Clerk 4.ELicensing Board Contact Person: Citv or Town: Issuing Authority (check one): lflBoard ot Health 2.! Buitding Department www.mass.gov/dia Applicant I nformation Plcasc Print l,cgibly Information and Instructions Massachusctts General Laws chapter 152 requires all employcrs to provide workers' compcnsation for their employees Pursuant to lhis sta,hxe. an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or writlen." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the recciver or trustee ofan individual, partncrship. association or other lcgal entity. employing cmployees. However, the owner ofa dwelling house having nol more than three apartments and who resides therein, or the occupant of the dwelling house ofanother 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 emplol.rnent be deemed to be an employer." M(iL chapter I 52, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opcrate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall entcr into any contract for the performancc of public work until acceptable evidence ofcompliance with the insurance rcquirements of this chapter have becn presented to the contracting authority." Applicants Please fill out the workers' compensation aflidavit completely, by checking the boxes that apply to your situation and. if necessary, supply your insurance 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 mcmbers or partners, are not required to carry workers' compensation insurance. Ilan 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 date the affidavit. Thc affidavit should be retumed to lhe city or lown 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 Dcpartment at the number listed bclow. Sclf-insurcd companies should enter their self-insurancc license number on thc appropriate line. City or Town Officials Plcase be surc that the afiidavit is complctc and printcd legibly. Thc Department has provided a space at the bottom of the affidavit for you to fill out in the evcnt 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 permiVliccnse applications in any given year, necd only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town nral'be provided to the applicant as pruol'thri a valid affidaYit is on file for llture pemiits 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 venture (i.e. a dog licensc or pcrmit to bum leaves ctc.) said person is NOT requircd to complete this affidavit. The Office of Investigations would like to thank you in advance for your coopcration 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 Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de [,afayette, Boston, MA02lll-1750 Tel. (8s7) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/20t9 WWW.maSS.gOV/dia iQo'CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMBER: CERTIFICATE HOLDER CANCELLATION REVISION NUI$BER o 1988-2015 ACO 06/09/2025 LYCERTIFICATE FICATE THISETCERTIFEcTPONHIGRUHTSoNYcDONFERSLONFTToERASDTEISSUEtsERTIFctcEStsTHICEPOLTHBDEDORRTEHTEDNRoLEXTELYRoEGNTIVEEFIRMDOESNOTRI2EDoTHNGTHSSUEET\^JE NNTRACTococNTUTETI00SEOTNESINcU RANCERTITHIS EoR.TEFICA OLHETHERTIcANOPORUROOCER,ERESttT TIVERE MPORTANT: rsed,beSNDUREoNALhDDITpiesusthNUSERoPolicv(DIADTIONALtdhortificatethtf statersementrtatclquiremaythpodditionstotermsDErsROGABTIONsubjectslfUholdehcertifithhtslodrtificeteisthEnca ll. O'Connor Aqs8E$- )4t!:o!q!!q qovEj4qELNSIJ eoconnor@ hartinsurancoagencY.com AMGUARD INSURANCE COI\4PANY AMTrust lnsurance Co A1387 I(SURER B - r ll{c'!l)HART INSURANCE AGENCY, INC 243 MAIN STREET PO BOX 700 BUZZARDS BAY. MA O2532O7OO lNsuREo Colonial Acres Resort Association 114 Standish WaY west Yarmouth. MA 02673 Ex- T L]CYPO RtooPEORHEA[1N AAOVEl-lT NS REDDoEEINssuLOWENSNCETPOLtclOFSCEIITHAitlTISsIO THoTHISICHPERESCT[1U NTEToHEDOCORONocONTRACTIJcORNoDTTEENtR:t4 TDNGANYOUEoNTWlTHSTTEDLNDICA TE SHETEB.l IOCTuERENsLlSESDRICEaDPOcESFORDBYEDTNSIJRANCEHEPENt)L ORBESUS cDLAIMSCEDUAYHVEENEREDSHSNowMIIHTONoSUCANScDDONCL:x ON .ADDT-SUB-R AES1230693 02 GENERA! AGGiEGATE 2,000,000PRODIJCTS. COMP/OP AGG A y' co ERclaL GEllEttal LIAglLn_Y cr-rrvs r,6oa y' occun s 1,000,000 1.000,000 2,000,000 100.000 5,000 P€RSONA! & ADV INJURY i O1|UDA25 01101i2O26 EACHoccuRRENcE AL]TO OAIELIAAILITY 500,000 ERI , {Elalc<rbnll - s aao1t2024 0810112025 trOFFICERAIEMAER EXCTL]DED' !!9ni4]-- EXCESS L|,AB .rEG E L EACI.]ACC OENT 10p.,099 500.000 ] *"ro""rnne"cg AGGREGAlE OWNEO HIREO BOOIIY INJURY (P6rP.Mn) S soOILY INJURY (Pe a@den0 i S EL OISEASE. EA EMPLOYEE S E L. DTSAASE- POIICY lrMlT S V'ORXERS COI{PEilSANON AI{O €'IPI.OYERS' LIABIUTY ANYPROPRIETOAJPARINER€XEC!- VE Dfsc oEscFrPTrot{ oF oPERAnoxs / locanoNs /vElrlcLEs {acoRo 101 additrohrl R.m.ri. sch.dul.. m.v b..tt ch.d n6d 'p'c' i' ttqlmd) SHOULO ANY OF THE ABOVE OESCRIBEO POLICIES BE CANCELLED BEEOREili;'&;,ilrti ;aii ineneor. NorrcE wttL BE oELNEREo rN ACCOROANCE V\IIIH THE POLICY PROVISIONS AUTHORIZEO REPRESEXTAIIVE Fax #: (508) 568-9234 Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 ACORO 25 (2016/03)The ACORO name and logo are registered marks of AcoRo RD CORPORATION All rights reserved HOLDER.INFORMATION COVERAGEAMEND.INSURER(S), aELOW. policy, -Ll?!90- HAV=LISTEOTHE TI.]ECERTIFICATEPOLICIES, s s GEN'LAGGREGAIE LIMII APPLIES PER y' leoucv tA Loc s cowc551052 S i-- s s SCHEOULED OCCUR CI.AIM9UAOE