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Home My WebLink About2025-26JUN ? h: '10?5 Lrcr:\sr, lr:r: Sr,i, BHHl4 -23-t83t !o o HEALTH DE;- 2025/2026 HAN COMPLETE PLEASE CO]\TPLE ALL OLESTIONS TOWN OF YARMOUTH BOARD OF HEALTH DLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 SSCAflIiTD( Ptor saX$#^S.l;i')*, - Fvs -L)3 zNAME oF BUSrN.r, DAtts 3cv n'r 6l Ai-27 ues.|- 1q,,"-u-aa lh+BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS olilt-j Cs** rts A;.-J tr.MAlL ADDRESS d^rrSi.'r^.,.r.,t<CoA @t .t16r-c". I ' L'' BEqTJ.TBEDMANoo*,-il.r**** ti^ i* L. I fA ^rTELEpHoNEo &Y --716 - L1>0 9 RI'OTIIRFD OWNER NAME il.u,^,ur.o )ok- 1)s'2 7 3 2 H.ME ADDRESS S "--z h S a.Lr-u-€- CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TEL. f MAILING ADDRESS TAX ID (FEIN OR SSN)RE9STRED Za ' g7q 093 6 LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PzuOR TO REOPENING. Town of Yarmouth taxes and lg'rfs .ust be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes 7 no- n.a Under Chapter 152, Sec. 25C. subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany license orpermit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you mus( complete the enclosed Workers Com ensation Affidavit. lf not a licable lcasc ex lain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE A\\' NE\l' CHE}II('ALS }IUST B RE.APPROYED B}' THE HEALTH DEPART}IE\T. RENEWAL APPLICATION -r' APPLICANT'S SIGNATURE Nt:\V i\PPLICATION DATE )s Fl-=,g!+ r :;, 11x.1is,1604 N N 06 Aonlicant Information Please Print Le ibtg Pr, , D-u *^O/> trti >vAddress: CirylSrilelZip:\AJ Y Gr s.1 llr^, h 4 aZ Phonc #276 ty t$S reyo employer? Ch€ck the appropriate box: I am a employer with employees (full and/ A l. 3 4 or part-time). * 2. E I am a sole ptoprietor or partnership and have no employecs 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, $l(4), and we have no employees. [No workers' comp. insurance required]++ We arc a non-profit organization, staffed by volunteers, with no employees. [No workers'comp. insurance req.] *Any applicant that ch€cks box #l must also fill out the section below showing their workers' conrpensation policy information. **lf the corporate oflicers have exempted themselves. but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. Retail Restaurant/Bar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment l0.E Manufactunng Ar/. //o4,//CIt2 l-'te LIIE Business Type (required) Health Care 5 6 1 I am an employer that is p Insurance Company Name rovidin g workers' compen satiolt, AJ-, hu!^^ l ' insurance for my employees. Below is the poliq' information. AsSrcicnlsJ €^bqt r9 J-su rvv.*Zlnsurer's Address |f'.po 3"r Q/?( UoBuA,t//bl OtFrt'9r?/City/State/Zip Policv # or Self-ins. Lic. #Wcc-soo - SoL??so -lozr A Expiration Date Oo /ol/ Zoz I I do hereby certifl',under tlr Q Si nature Phone # ins and penalties of perjury that the inlormotion provided abore is true and correcl Date d{////2 S Say - 1z S- 233 z Olftcial use onll', Do uot write in this area, to be completed by ciq or ot'n olJicial, lssuing Authority (check one): I flBoard of Health 2.E Building Department 3^E Ciry/Town Clerk Permit/License # 4. ! Liccnsing Board Phone #: City or Town: 5[ Selectmen's office 6. Eother Contact Person: The Commonwealth of Massachusefis D epartmen t of I nd ustrial A ccide n ts Olfice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass,gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: l Attach a cop) of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the tbrm 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 totheOffice of Investigations of the DIA for insurance coverage verification. www.mass.gov/dia Information and Instructions Massachusetts Gencral Laws chapter 152 requircs all employers to provide workers' compensation for their employees Pursuant to this statule, at employee is dehned as "...every person in the service ofanother under any contract ofhire. express or implied, oral or written." 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 receiver or trustce ofan individual, partnership. association or othcr lcgal cntity, employing employees- However, lhc owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another 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 cmployment be deemcd to be an employcr." MGL chapter I 52, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a liccnse or permit to operate a business or to construcl buildings in the commonwealth for any applicant who has not produc€d acceptable evidence of compliance with the insurance coverage required." Additionallv. MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract for the performancc ofpublic work until acccptablc cvidence oicompliance with lhe insurancc rcquircmcnls of this chaptcr havc been presented to thc contracting authority." Applicants Please fill out the workers' compensation alfrdavit 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 ofinsurance. Limited Liability Companies (LLC) or Limitcd Liability Partncrships (LLP) with no employees olher than the mcmbers or partners. are not required to carry workers' compensation insurance. If an 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 ol insurance coveragc. Also be sure to sign and date the aflidavit. The affidavit should be retumed to the city or to\.!,n that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Dcpartment at the numbcr listcd below. Self-insured companies should cnter their self-insurance license numbcr on thc appropriate line. City or Town Oflicials Pleasc be surc that the aflidavit is complete and printed legibly. Thc Dcpartmcnt has provided a space at thc bottom of the affidavit for you to fill out in the event thc Office of Invcstigations 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. In addition, an applicant that must submit multiple permiVliccnsc applications in any givcn year, need only submit one affidavit indicating current polir:y irformation (ifncccssary). A copi.'of the n{fidavit t}tat has bccn o{ficially stamped or marked by the ciryor k,rm may be provided to the applicant as proofthat a valid allidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or cilizen is obtaining a license or permit not related to any business or commercial venturc (i.c. a dog license or permrt to bum lcavcs ctc.) said person is NOT required to completc this a{Iidavit. The Officc of Investigations would like to thank you in advancc 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 Lafayette, Boston, MA02lll-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7i20t9 wwwmass.gov/dia fffNrt Mutual A.t.M. Muhral lnsurance ComPanY Massachusetts Employers lnsuranco Company New Hamoshirs Employ6rs lnsuranco Company Associated Employers Insurance company lnsulance ComPanies WORKERS COMPENSATION INSURANCE B]LLING STATEMENT Prg.: Pari D€vang CorP 69 MAIN STREET WEST YARMOUTH, MA 02673 lf a prsvi ous balance aPpears on Your statoment, a Portion of the Cutront Balancs shown may bs due earlier lhan $e due dats shown ll payment has been rgmitted, Pledss disregard billing statoment Policy is subject to audit For bllllng lnquirie!, pleerc call (800)E7G2765 54 Thlrd Avonuo'P.O. 8or lo70'Budlngton' MA 0'1803'0970 V-.^'<-) t 1-... ( {\, q0 (- tI \[ , g\t+ ,so-2025Awcc-50G 5027Policy Numbet: 619t202iatstzozaPolicy Totm 5l'1512025Stat€ment Date: 818',11427Statement Number: 61912025Due Date: $254.00Amount Due: (n on Prsvious Statement Balance $8.00 Down Paymont DIA Assessment $246.00 Down Payment Premium05t15t25 Tear Here Pay your Promium bY m.il: ln3tructlonE: i. -li"i, "t'-".* p"v"ule to A.l.M. Mutual lnsuranca Company z. incluoe your eoticy Numb€r on ule Check'i bii".*t il,t "tru "lto rotum wifi paymont in th€ endosEd env€lope wcc-s00-5027250-20254 026 $1,016.00 5027250 81811427 5l't512025 61912025 Policy Number: Policy Term Policy Pr€mium & Surcharges lnsured Numben S tement Number: Due Dat6: Amount Duo 0a 0ol,8l,1t{?? 00r11?l,tl3 001 000000a5q00 0 500 t254.00 I of 'l \ \1 a Or Pay Yout Promium online: lnttructlons:I Navidate to wtYw.aimmuh,al comi lil"i"trr" 'iav Your PrQmium' link at the top ot ulo pale i. ilp"iiri" t"r"'r""t ttorietion lound on this statom€nt' lnsurod: Pari Dsvang CorP Associatsd Employers lnsurance Company (500) P.O. BOX 4131 woBURN. MA 0188&4131 Amount 05t15125 EGtement Date: