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Home My WebLink About2025-26REGtrlVEO JUL 1't ?025 H HAN D tkM. 62t.t0 LICENSE FEE $I50 Eatrt'231ebq Co\IPLETE THIS .\PPLI('A'I'IO\ ,\\D RETTIR\ IT \\'ITH THE I-ICE\SE FEE BY JUNE 30. 2025 TOWN OF YARIIIOUTH BOARD OF HEALTH In.-G AND STORAGE OF TOXTC OR HAZARDOUS MATERIALS LICENSE APPLICATION PLEASE CONTPLETE ALL QUESTIONS NAME OF BUSINESS BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS 5a rn-c BUSTNESS rsl. * .SOY .1'l I . 3 (. (- +rJ l{Aoza)3 EMAIL ADDRESS 4) REOL I R[D MANAGER/CONTACT PERSON (V1;.)no< I l:a or)s TELEPHoNE * S7 ^ -1 'J l.3c,u G r xt u3z RFoUIRFII OWNER NAME h, <-1.-t a,e t Ed uto--)-<rer.* -lPf, .Zlo1. lqo HOME ADDRESS CORPORATION NAME (IF APPLICABLE)N/A HA OLG L rEL. # U/n CORPORATION ADDRESS A)/A MAILINGADDRESS N / N Oq- cs1 L?-q Ll LICENSES RUN ANNUALLY FROM JULY I TO JU}IE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JIINE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARI RECETVED. 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 Com nsation Affidavit. lfnot applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED appropriately ifpaid: yes-!- no- nr'a Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required lo hold issuance or renewal of any license or permit to operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As part ofihe renewal or issuance ofyour permits. you must complete the enclosed workers CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED '/YN ALL SAFETY DATA SHEETS ONFILE ,/ yN ANYNEwCHEMICALSMUSTBEPRE.APPROVEDBYTIIEHEALTHDEPARTMENT. RENEWALAPPLICATION J NEWAPPLICATION- APPLICANT'S SIGNA DATE €scrur:c TAX ID (FEIN OR SSN)RE@,IBED a/zs/rs iQo'CERTIFICATE OF LIABILITY INSURANCE 'THIS CERTIFICATE tS ISSUEO 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 AFFOROED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO REPRESENTATIVE OR PROOUCER. AND THE CERTIFICATE }IOLOER. COVERAGES CERTIFICATE NUMBER: 870879047 REVISION NUMBER 4t212025 IMPORTANT: lf the certificate holder is an AODITIONAL INSUREO, th6 policy(ies) must have AOOITIONAL INSURED provisions or bo endorsed It SUBROGATION lS WAIVED, subject to tho terms and conditions of the policy, cedain policies may require an Gndorsement, A statement on hts to the certificate holder in lieu ol such endo6emont(s).this certificate does nol confer rig II{SURED COVEATY41 The Cove at Yarmouth Resort Owners Association. lnc. The Cove at Yarmouth Resort Hotel Homeowne/s Association, lnc. 183 Main Street West Yarmouth MA 02673 877-816-2156 L ers I a Under 800-553-1801 mail AFFORDING COVERAGE com 13037 44776 34754 lnsurance PROOUCER Rogerscray A Baldwin Risk Partner 410 Unrversity Ave Westwood MA 02090 I SURER a, Massachusetls Retail Merchants TNSURERBi The Cincinnati rNsuRER c: The Commerce lnsurance INSURERD] SIATSTONC S THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I INDICATEO. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONOITION OF ANY CONTRACI OR OTHER DOCUMENT WITH RESPECT TO WHICIl THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED BY THE POLICIES OESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS SSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOO EACH OCCURRENCE MED EXP PERSONAL A AOV LNJURY GFNE RAL AGGRE6ATE X 4t112025 4t112026 PROOI]CTS . COMP/OP AGG B $2 000 OTHER GEN'L AGGREGATE LIMIT APPLIES PER: POLICY t 1 000,000 t 100 000 !0 s 1,000,000 s2.000.000 Erl& E.o" cr rM$MAoE f *"r" t"l X 41n42641n425AI]TOMOBILE IIABI!ITY L'l9'121c ! 1.000.000 T;_] scHEouLEo^ laurosi;] NoNowNEo| ^ I auros oNLY T env nwo I OWNED AIJTOSONLY AUTOS ONLY s5,000 000 15,000 000 EACHOCCURRENCE AGGREGATE S 411/2426I qtlnozsGP06-24-1792125UMBRELLALIAB EXCESS IIAB OCCURoxx DED x 111t2025014005035505124 X 51,000 000n t 1,000 000 t 1,000,000 EL EACII ACCIDENT E L, OISEASE. POLICY LIMIT E L OISEASE. EA EMPLOY WORKERS COMPEISANON AIIO EXPLOYERS' LIAEILI T ANYPROPRIETOR/PARTNE&€XECI]TIVE OFFICERTTiEMBEREXCLUDEO? oEscRtpL,N oF opER^noirs / LocAIoNs / vEHtcLEs (acoRo l 01 , addltion.l R.m.rt. s.h.dul., h.t b. .tt ch.d It oor .p.c. l. ..qstnd) Prooertvi The Cove at Yarmouth Resort ol^,ners Association, lnc. '183 Main Street West Yarmouth MA 02673 Nuibei ol Buildinos 3 - Total LJnits 229 Special form. Repfacement cost coverage applies. Buildina Deductible: $50,000 Ordinaice or Law'Coverage A - lncluded in Building L'mit Ordrnance or Law - Coveraqe B & C _$5,000,000 Maximum per occurrence Named Stom: 2% ol Total Insurable Values per occurrence, subject to $50.000 minimum All Other wnd/Haii: S50,000 per occunence See Attached... CERTIFICATE HOLDER CANCELLATION Town of Yarmouth Route 28 South Yarmouth MA 02664 SHOULO AI{Y OF THE AAOVE OESCRIBED POLICIES B€ CANCELLED BEFORE IHE EXPIRATION DATE THEREOF, NOTICE WLL AE DELIVERED IN ACCOROATICE WITH THE POLICY PROVISIONS, O 1988-2015 ACORD CORPoRATION. All rlghts reserved ACORD 25 (2016/03)The ACORo name and logo are registered marks ot ACORo X S csu 01E556ECOMMERCIAL GENERAL LIAAILITY BoolLY INJURY (Par aedenl) BOOILY INJURY (P€r ps6on)s I S s OTH'1t1na2i tr