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Home My WebLink About2025-26cp * gatb I a3- ltLICENSE FEE: $ 150.00 TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE J0.2025 ./-\ PLEASE COMPLETE ALL QUESTIONS NAME OF BUSINESS Daya,npolt fle4llr flqst BUSTNESS 161. 6 508 398 2293 BUSINESS ADDRESS tN yARMOUTH 31/33 Marlin Way S. Yarmouth, MA 02664 MAILING ADDRESS 20 North lvlain Street, South . Yarmouth, MA 02664 SlSCijil;lD EMA IL ADDRESS cdavenport@thedavenportcompanies.com REQUIRED MANACER,'coNTACT PERSON Christian Davenport TELEpHSNE E 508 314 329'1 REQUIRED owNER NAME Davenport Realty Trust HOME ADDRESS 20 North Main Street. S. Yarmouth, MA 02664 1E1-.a 508 398 2293 CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TE L, ; MAILINC ADDRESS 04-2208671 LICENSES RLIN 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 CLOSURE OF YOUR ESTABLISHMENT LTNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. 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 appropriately ifpaid: yes_! no nla Under Chapter 152, Sec. 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal of any license or permit to operate a business ifa penon or company does not have a Certification of Workers Compensalion insurance. As pan ofrenewal or issuance ofyour permits. you must complete the enclosed Workers Compensation AIIidavit. Ifnot applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE YN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMINT. RENEWAL APPLICATION X NEW APPLICATION X N X APPLICANT'S SICNATURE DAI'E c /,,1,L> TAX ID (FEIN OR SSN) EEQTIIBEP /t**jhu,-*,t-- The Commonwealth of Massachusetts D eparl menl of I n duslri al Accidents Ollice ol l nvesrig ions Lafayette City Center 2 Avenue de Lafayette. Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation lnsurance Affidavit: General Businesses Business/Organ ization Name: Davenport Realty Trust Citv/Stare/Zip South Yarmouth. IVA 02360 phone #: 508-760-9256 Business Type ( required) 5 6 Retail Restaurant/Bar/Eating Establ ishment 7. En Ofiice and/or Sales (incl. real estate. auto. etc.) 8. 9. l0 lt t2 Non-profit Entertainment Manufacturing Health Care Other .Any applicant that checks box #l must also fill ou1 the section below showing their workers' compensation policy infotmation. .*lfthe corporate officers have exempted themselves. but the corporation has other employees. a workers' compensation policy is required and such an organization should check box # l. I um an employer thot is providing workers' compensalion insurance for my employees. Below is the policf infomolbn. Insurance Company Name:Zurich American lnsurance Compay lnsurer's Address: see attached CiWlStatelZip Policy # or Self-ins. Lic. * WC8'1961 32 Expiration Date 3t1t2026 Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date)' Failure to secure coverage as required under $ 25A of MGL c. I 52 can lead to the imposition of criminal penalties of a tine 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 ol'up to $250.00 a day againsr the violator. Be advised that a copy ofthis statement may be tbrwarded to the OlIice of lnvestigations of the DIA for insurance coverage verification. I do hereby c ure the pains ond penahies ol perjury lhal the inJirmution provided ahove is ttue qnd cofiect. )Lrt t rl 7L ,2czs 508-760-9270Phone #: Ollicial use on$. Do not b'rite in lhis orea, to he completed by ci4' or town olficial. Contact Person: Phone #: Permit/License # 3.8 City/Town Clerk .1. E Liccnsing Board City or Town: Issuing AuthoriO (check one): l.EBoard of Health 2.E Building Department 5[ Selectmen's office 6. flOther wwu,-nrass.gov/dia Apolicant Information Please Print Lesiblv Address: 31 / 33 Marlin Way Are you an employer? Check the appropriate box: t. E t am a employer with - employees (l'ull and/ or part-time).* Z. E t am a sole proprietor or pannership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. n We are a corporation and its oflicers have exercised their righl ofexemption per c. 152. tl(4). and we have no employees. fNo workers' comp. insurance required]*{ 4. I We are a non-profit organization. staffed by volunteers. with no employees. [No workers' comp. insurance req.] A,CORD DAVEREA.Ol CERTIFICATE OF LIABILITY INSURANCE 2t10t2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COIIFERS NO RIGHTS UPON THE CERTIFICATE HOLDER' THIS CERNFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES iIOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. tMpORTANT: l, the certltlcate holder is an ADDITIONAL INSUREO, the policy(ies) must have AOOITIONAL INSURE If SUBROGATION IS WAIVED, this certificate does not conler ri D provisions or be endoBed. ent.tatemesntmreaendciesrmsonconditiotstherequaytepopolthetoectsuicybj tin ofeu hsuc end mersetocetheifirtatecoldeh 484 965-9627458-35591 AmericatNs a PROOUCEi Vellev Fo.oe CaDtive Advisoa3 E. K. cco-nkev & Co..lnc. 630 Faeadom dusiness Centor Ddve Klng Of Prussia, PA 19405 IJRER BI I IN D IN INSIJRER F Davenport Realty Trust 20 Nonh Main Street South Yamouth, MA 02564 INSUREO RA FICATE N oEscRFnoN oF opERATtONS I LOCAiONS r VE8ICLES TACORD 101 , Addirion.l Rem rr. schldur.. mv b. .n..h.d ll do6 .p.c. B Equied I CAT REVISIO O 1988-2015 AcORD cORPORATION. All tights reserved SHOULD AtIY OF THE ABOYE DESCRIAED POLICIES BE CANCELLEO AEFORE THE EXPIRATION OATE .IHEREOF, NOTICE wlLL AE DELIVERED IN ACCOROANCE WTH THE POLICY PROVISIONS,Town ol Yarmouth Route 28 South Yarmouth, MA 02664 STAN PERTAI FO ETH LIPOCY E toRDTHUlNsEDABOVNAIJEDEHBISESUIOEDLSTEBDELOWVEEENTHToESNUScRANETRETHATIFYPOEtcrSItTOrsCHISTHTRETHSPTOCoHEOTDOCRENU[,1OFCONYNTRACTONDITIToERI\I CRONNTDINGRNYUEOlRElvlENOTWTHTE0NDI T RMSBJECTTOLHETERIBDESCHEDEEINSSUDDETHBYPOLtCIEESNSURANNCEFFOETHDORFITEBEISSUEERcTICAEDBcDLAIMSHBEVERENEOUCPOLHES.rct t4LI sITSHO\.^/NNCDSONDITIONSUOFcEXCSIUONS ,000x,000,000Nr€o 1,0005l,Ec 1,000, 2.00L 2,000.x 31112026LO8'1S6255x TE LIMIT A tr C!AIMS-MAOE PER LOC 1.000.000LE LIMIl x E s 31112025 3t1t20268AP8196256 AU'OMOBILE LIABILITY OVINEDAUTOS ONLY HIREOAL]TOS ONLY SCHEDULEOAUTOS NON'I{NEOAt]TOSONLY c I OCCUR CIAIMS.MADE cEr RETENIIONS x 1.000.t.[ 00,000SEL1,00sMTE,L OIS 311t202s 3t1t20268196132 WORIGRS COIIIPENSANONANO EMPLOYERS' LIABILITY ^NY PROPRIETOR/PARTNER/EXECUTIV€OFFICER/MEMBER EXCLUDED' I 41-/z- AUTIiORIZED REPRESENTANVE ACORD 25 (2015/03) The ACORD name and logo are registeted marks of ACORo cenarnand 3t112025 COTIIMERCIA L GENERAI- !IAAILITY OCCUR tr