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RNIOUTH BOARD OF HEALTH
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RAGE OF TOXIC OR HAZARDO US MATERIALS
COMPLETE THIS APPLICATION AN
ENSE APPLICATION
D RETURN IT WITH THE LICENSE FEE
L',ENSE FEE $tro Brt H r,t - z3 - l11l
025
NAME OF BUSINESS a o
B\' .ltl\E 30. 2
c
S
P BUSINESS TEL, #x )t{
BUSINESS ADDRESS IN YARMOUTH
JUN1t]tu108h Y
HA}rl .ljlL:-DSTI
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MAILING ADDRESS
EMAIL ADDRESS
REOUIREDMAN AGERYCONTACT PERSON
TELEPHONE #0 b A L/oo
Rl-ou lR['' l)OWNER NAME
HOME ADDRESS
CORPORATION NAME (IF APPLICABLE)
CORPORATION ADDRESS
MAILING ADDRESS
TAx ID (FEIN oR ssN)REOUIRED
LICEN
TEL.#
A
TEL. #
Certification of Workcrs ComPensatton
n
RESPONS IBILITY TO RF-Tt-]RN
LY FROM JULY I TO JINE 30 IT IS YOUR
30. FAILURE TO DO SO WILL
SES RUN ANNUAL QUIRED FEE(S) BY JLNE
RESULT IN CLOSURE OF YOUR ESTABLISHMENT INTIL THE REQUIRED APPLICATIONS(S) AND
THE COMPLETED APPLICATION(S ) AND RE
OF HEALTH MAY BE REQUIRED PPJOR
AHEARING BEi--ORE THE BOARD
FEE(S) ARE RECETVED Gase check
TO REOPENING or to renewal or lssuance ofYour Permits' P
Yarmouth taxes and liens must be Paid Pri
Town of
red to hold issuance ot renewal of anyno-a-
pproPriate ly ifPaid: Yesa
Under ChaPt
license or Perm
er 152, Sec. 25C' s
it to operate a bu
ubsection 6' the T
siness ifa Person o
own of Yarmouth is requt
r company does not have a
lor issuance ofYour Pennlts.you must complete the enclosed Workers
insurance. As Part ofthe renewa plicablc,rrleas e cxPlain
omPe nsationAlfidavit. lf not apC
REGISTRA TION FOnu stcNe DANDC OMPLETED
CHECKANDWORKERSCOMPAFFIDAVITENCLOSED T
N
ALL SAFETY DATA SHEETS ON FILE - " N
ANY NEW CHEMICALS MUST BE PRE'APPROVED BY THE HEAiTH DEPARTMENT'
RENEWAL APPLICAT'ION
APPLICANT'S SIGNATURE
/ NEwAPPLICATI.N-
DATE
€sumn
o
(
ofas/es
ACORT)CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A IIiATTER OF INFORMANON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR t{EGATIVELY ATIENO,EXTEND OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES
BELOW. THIS CERNFICATE OF INSURANCE OOES NOT COTSNTUTE
REPRESE'{TATIVE OR PRODUCER, AI{D THE CERTIFICATE HOLDER'
A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
=i::,..AN-i It the co mcato holdor is an AooIIONAL INSURED, tho policy(ies) must have ADDITIONAL INSURED provisions ot be endoEod.
--IgROGATION lS WAIVED, gubioct to lhe terms and condilion3 ot tho polacy, cortain policies may requite an ondoBeme nt. A statement on
this certificate does not confor to the cortiticats holde. in li6u ot such en
COVERAGES CERTIFICATE NUMBER: 11293Y REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
O 1988-2015 ACORD CORPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORO
Town of Yarmouth Health Department
1146 Roule 28
South Yarmouth MA 02664
I
SHOULD A}{Y OF THE ABOVE DESCRISEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION OAT: THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDAXCE WTH THE POLICY PROVISIONS,
AUTXORIZED RE PRESE NTATIVE
Daniel M Crowley, CPCU, Vice President - Residual Market - WCRIBMA
06t2312025
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TRAVELERS PROPERTY CAS CO OF AM
INSIJRERD
Stephanie Pedro
(508) 235-2292
2567 4
INSURER E
PROOT'CER
HUB INTERNA] IONAL NEW ENGLAND LLC
l\rlA 02061
MA 02675
203 C WLLOW ST
YARMOUTH PORT
600 LONGWATER DRIVE
NORWELL
INSURED
COYS BROOK INC
HAVE T rc E DRroBOVEFOREHPOLHET!SU EO oAMEEEUDETOEBDOWELOFESSUcNSTERTTTHAHTPOELlctsTHIScTO T tc THH STHSPECToEHTEocuDEMNTANCNTRooACTooEE[/TNSTDNNGNYoEUNOIW THDICANEDT ETH RIlISTETOECTLBHDRENEIsrsBJUPOLEScCDESTEHRANEOREDEDSUcHETTNDORETERCAETBESSU EC t/lEI]c B o SCENEEEDURESl\llT SHsov\ tNsOFCUPOHLcSroNoNcoDTtoSEXCSU
EACH OCCURRENCE
sESEa
s
PERSONAL& ADVINJT-]RY
PROOUCTS - COMP,OP AGG
GENERALAGGREGAIE
N/
PoucY I lSic$ I I
.-i,. JGGRECITELMITAPPLIESPER
LOC
COMMERCIAL GEN ERAL LIABILITY
claBs-MAoE [ *"u"
BOoTLY INJURY (Perpe6m)
BOOILY LN.IURY (Per accd6.l)
AU'IOMOBILE LIAEILITY
SCHEDULEOAUTOS
NON-OWNEO
AUTOS ONLY
5UMBRELLA LIAB
EXCESS LIAB AGGREGATE
OCCUR
CLAIU$'MAOE
RETENTIO
5 500,000
STA
E L EACHACCIOENT
5 500.000
s 500.000
EL O]SEASE - EA EMPLOYEE
E L DISEASE. POLICY LIMIT
10101t2024 1010112025TPJUB{863P40824
woRxERs corrPENsarloltl
Ato EiTPLoYERS UAAluW
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICERAIEMBEREXCLUDEO?
OESCRIPIION OF OPERA
OESCR|PnON Of OPERATIO|{S / LOCATIOIiS / VEHICL.ES IACORO 101 Addidodt R'mrtt Sch'duh, Nv b' 'tr'h'd
Workers, Compensation benefits wi be pard to Massachusetts employees only Pursuant to Endorsement WC 20 03 06 B no authorization is g'ven to
iiy craimi ror'Gneris to employees in &ate" otn"i tt "n Mi""""t useis rf trreinsureo hires, or has hired those employees outside ol Massachusetts
This certific€te of insurance shows the poticy in force on the date that this certificate was issued (unless the expiration date on the above policy
pre-eaes tne issue aate of this certificaie ofinsurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -
boverage Verification Search tool at www.mass.gov/lwdl orkers-compensation/lnvestigations/
ll hore !p.c. i! cqulBd)
ACORD 25 (2016/03)
rNsuRERts) AFFOROING COVERAGE_
TNSURERC: r
r
, TER[' OR CONDITION
s
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s
$
5
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L ,_-.1I lowvEDI I AUTos oNLYT--.l HrREoL l AllrosoNLY rl
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