HomeMy WebLinkAbout2025-26Ch.No 17a22
LICENSE FEE S I50 E\HH/I-23-tQ7a
TOWN OF YARNTOUTH BOARD OF HEALTH
202512026 HANDLINC AND STORACE OF TOXIC OR HAZARDOUS MATERIALS
LICENSE APPLICATION
COMPLETE THIS APPLICATION AT\D RETURN IT WITH THE LICENSE FEE
BY JLrNE 30, 2025 /-\
<s" scfiiliEDPLEASE COIIIP -4LL OU ESTIONS
NAME oF BUSTNESS DRYTOALL NCSO,Jtr.I
A,L4ppLte5, t$O
BUSINESS ADDRESS IN YARMOUTH
MAILING ADDRESS
BUSTNESSTEL.+ 5;D nb 4lN
2-11 6tfrTE- PATFI
Sourrr Ykp.rttoartt MA OZato+
i c,
L,MAIL ADDRESS
REOUIRED MANAGER/CONTACT PERSON
TELEPHoNE# iffi 741) 4 t032
4.,D LJ-A S
Kn-ISTF,..] CPo N\RN]
RFOUIRFN OWNER NAME
uoueeorn-ass 34R SIMOI.B DD MASITPST MA b2b4A
CORPORATION NAME (IF APPLICABLE)-TEL. #
CORPORATION ADDRESS
Lours l4cLrutgrrr rct.+ 0D2> 4oo +laz
TAx ID (FEIN oR SSN) REOUIRED O+ - 2Eqo2t4
LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOT,'R 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 UNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED, A HEARING BEFORT THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
TO REOPENING.
Town ofYarmouth taxes and li_ens must be paid prior to renewal or issuance ofyour permits. Please check
appropriately ifpaid: yes :4 no- n/a
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 person or company does not have a Certification of Workcrs Compensation
insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers
Compens ation Affidavit. tf not app[cablc, plcase cxplain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED r'
YN
ALL SAFETY DATA SHEETS ONFILE -__4yN
ANYNEwCHEMICALSMUSTBEPRE-APPR0VEDBYTHEHEALTHDEPARTMENT.
RENEwAL APPLICATION / NEW APPLICATION_-
APPLICANT'S SIGNATURE:Dere, L0 '1 7 z2
MAILING ADDRESS
Th e Co mmo n weo llh of lll as soc h us ells
., -L Departmcnt of Induslrial Accidents
i...," Oflice o/ lnrestigotions
' I,j Lolayette Ci4, Center;'- , 2.4venue rle LdIq'ene. Boston, trt.4 02ltl-1750
x,wn'.mass.goty'dio
\\'orkers' Compensation lnsurance Aflider.it: General Businesses
Please Print Lesiblr'
T,dALL MA OA.)VQPLte (:
Address: 2-11 tol-h rrES PeDl
C rty Statc Zip S YAPnuD4 mA o2t"m;5b8 3'i8 4 tO(,
or!Jr,/Jtrnr.hul,, Lh(l^ hl,\ " I
I on nn cnryhtyer lltut is protitlhtg *or*ers' conpen\otio irrt,,rotrct ltrr nr)' entplorces. Bclot, is thc polic)' irrrrm.trio .
lnsrrr.rncc ( onrprrrl Nrnrcr lr€Oe?pfVD lp5,g1z71p6g
tnsurur's Atltlrcss PO WX lZ-a
(ir\ srrrczrpr A[{)A?.lNfl4-r llA
P()L(\ ! or scll-rnr I ic : I 8q q bO I
550bo
.{llrch a cop! oIthe norkers' compcosrtion polict dccl.r.aior prge (rhotrirg lhe polict rumber rnd etpirrlion drlr).
Farlurc lo sccurc errr!'tugl' .r\ r!.qurr('J unrlcr t liA ol \l(it c M u.rn lcad rtr rhc rmposrlton ofcnmtnrl t^*nJllrci ol il lin!'uJt
tq S 1 .5(l( t lX) .rnd or on!'-)rJr tmpnsonm!'nr. as \i!'ll rs cn rl pcn.rltrcs rn lhc ti,rnl ol a STOP \\ ORK ORDER and I lir!!' r)l up l()
lhc Dl.\ tbr rnsuranc!' c()\critgc \erilicatlon.
I lo hereh; t'ertift, un cr lh c ltrrius und pcutltiet ol Verit n ,hot lhe inforuurion pro|i cl uhorr ir tnte u corraLl.
v*?)/l---D,rr. ll 25 2a?/+
Are tou 8n emplo!er? Check the rpproprirte bor:
L E I rnr a cnrpkrvcr *ith l tl emplo!'r'('s ttull and
or FlJn'llllrc)'I E I am a solc propri('ror or panncrship and harc no
cmplolcr,'s uorhrng lor mc rn an1 cupacitl.
_ [\o sorL.'ri rolnF! tnsurJnc!'I!'quired]
3 l--l t\ c .rrc l jirT'(rrJtrrrn JnJ rti rrtl]!'r'ri hrrc cr.'rir.c,.l
thcir nght ofcrcnrption pcr c. l5!.\l(.ll.andrrch.rrt'
nrr cmpLrlcc:i. INo uorlcrs'comp insurancc rcqurrr'd]'
l. ! \\',,'ar,,. a non-prolir organizarion. statTcd b1 rolunt.'crs.
rirlh no cnrplolccs. INo $orl!'rJ' comp. insuranc,,- rcq.l
Buringss T1.,pe lrequircdl:5 Pf Rcrarl
r, f Rr'itrtrr.rnt BJr t:.rting Est.rhlshrrrnt
I D Olilc{ und or Salcs (incl. rcrl !'Jtlr{r. uuk). crc ,
r n \('n.n()lit
v ! l.nrcrrarnm.'nr
l0 [ \l.rnulacturrng
I I fl lL-alth Carc
tl fl t)rhtr
l: rpirarion Datr' 1. I 2025
\ l:. r'tl -
3iE 4ta)Phortc tr
lssuing .{uthoritl (checl one):
iflgirrJ or H."r,h 2.E8lildiog Deparlmenl 3.Dcilt/Torrn ('lerli
5E Selectmen's Ottice 6. EOlhtr
Phone f:
{. E l-icensing Board
( oniacl Pt'r"on:
otc 0z
I
r
Busrness Organization Name:
Ollit'io! use outl'. Do ,rol b'rile in lhis orco, to be c.tnPl.tc'l b1' ci4' or ann olliciol'
Cirl or 'l onn: Pcrmil/Licenre #-
Information and Instructions
Nlassachus ts U!'ncral [-aus chaptcr l5: r.quir.'s all employcrs lo pro\ ld(' \! orkcrs compensation lbr their cnrplo\ccs
Pursuanl to this statutc. inr empl.r)'ee is delined as ...t'rer1 p!.rs{)n rnlhascr\rcc ofanothcr und.r an} contract ofhirc.
c\prcss or rmplrcd. oral or \\ntlen -
An emplol'cr rs dcfincd as "an indir idual. pannership. association. corporation or other legal entity. or any two or morc
ol the forcgoing cngagcd in ajoint cntcrprise. and rncluding thc lcgal rcprcscntatrrcs ofa deceased employer. or rhc
rcccivcr or lruslcc ol an indiridual. parmenihip. associ tion orothcrlegal cntity. . r'mploying employees. Horrercr. the
o*rrcr ofa dsclling housc haling not morc than thrr'e apanments and who rcsides lhcr(.in, or the occupant ofthe
dwelling housc ofanoth!'r $ho employs pcrsons l() do nrJint!-nancc. construction or repair *ork on such d*clling housc
or on thc grountls or building appunenant thcrcto shall nol bccausc ofsuch r'mployment be dcemed to bc an cmploycr."
lvlcL chaptcr l5l. \25C(6) also stat!'s that "evcr) slrte or local liccnsing rgcrc, shrll rrithhold the issuance or
renerel of r license or permit lo operrle a businels or lo co]rslruct buildings in ahe commonweallh for rny
applicsna rho has not produc€d .cceplrble evidence ofcomplirllce nith the insurarce coverrge requircd."
i\dditionallv. ltvlcL chaptcr 152, \l5C{7) states "Neitht-r thc commonwcalth nor any of its political subdivisioos shall
entc-r into any contract tbr the pcrfonnance of public work until accrptablc cridence ofcompliance with the insurarce
rcqulr(rndll\ ol lhr. ehrptcr hd\r b!'cn prssenlcd to lhL'conlractln{ Jtlrhr)rit\ "
Applicrnls
Plcase fill out rhc $orkcrs' compensation aflida\ il complctcly. b1 chccking the boxes that appl) ro your situation aod. it
nccessar). suppll your rnsuranc!'compan).-'s nam,c. addrcss and phonc numbcr along $ith a certificate ofinsurancc.
Limitcd Liability (\rmprnics 1LLCl or Limircd Liabilitl' Panncrships ( LLP) N'ith no employees ofier than thc rr*^mb!'ni
or panncrs. arc not rcquired to carrl u'orkers comp!'nsation insurancc. lf an LLC or LLP does have smployccs. a policr
is required. Bc adr iscd that this atiidavit may bc submincd to thc f)cpartment of Industrial Accidents for contirmation of
insurancc covrragc. Also be sure to sign rnd drte the rmdrvit. Thc. affidarit should be retumed tothe city or town
that lhc application tbr thc pe'rmit or licensc is b,,'ing rcqucstcd. not lh\' l)!'partmcnl of Industrial Accidents. Should you
havc any qucstions rcgarding the law or ifyou arc. rc'quirr'd lo oblain a workers' comp€nsation policy. please call the
Dcpanm€nt at lhc number listed below. Self-insured companics should enter thcir self-insurance license numbcr on thr.
appropriatc linc.
Citl or Town Of[icials
Plcusc bc surc that thc allidavrt is comp['tc and printcd lcgibly. Thc Dcpartmcnt has prorided a space at thc bottom
ot thc atlidavit tirr vou to lill out in thc crcnt thc Ollicc ot lnlcslruxlions h s to contact you rcgarding rhe applicant.
Plcasc Lre surc lo till in lhc pcrmi! licensc numbcr $hrch $ ill bc usr'cl as a rclcrence numbcr. ln addition, an applicant that
must submit multipl!' pcrmil license applications in anv gir,.'n 1cur. nccd onh' submit one atlidar ir indicating currcnt
policl informatton lrf n!'cL'ssary). .A cop) ofthc afliddrit that hrs bcen oflciallv sramped or marked b-v the cit\ or lo$n
may bc proridcd to thc applicant as Proofthat a lalid atlidavit is on tile tbr luturc permits or liccnses. A ncu aflidarrr
must be fillcd out each year. Where a honx or+Ter or citizcn is obtaining a license or permit not relared ro any busincss
or comnrcrcial venture (i e. a dog license or permit to bum leates etc ) said pcrson is NOT rcquired to complete thi.
allidar rt.
Thr' C)flicc of lnr estigations would like lo thank you in advance lbr your cooperation and should you hare any questrons.
pleasc do not hcsitate to givc us a call.
The Depanmenl's address. tclcphone and fax number:
The Commonwealth of Massachusets
Department of Industrial Accidents
OIfice of lnvestigrtions
Lafayene City Center
2 Avenue de Lafayette,
Boston. MA02lll-1750
Tel. (857) 3?l-7406 or l-ti77-MASSAFE
Fax (617) 727 -'fi49
Form Re\r\.'tl I :ote n,U.rv.maSS.gOV.,dta
Print FormANOTICE
TO
EMPLOYEES
FEDERATED INSURANCE
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
I Congress Steet, Suite 100, Boston, Massachusetts 02114-2017
617 -727 4900 - http://www.state.ma.us/dia
As required by l\'lassachusens General Law, Chapter 152. Sections I1,22 & 30, this will give you notice
rhat I (se) have provided for paymenr ro our injured employees under the above-mentioned chapter by
NAME OF INSURANCE COMPA}.IY
PO BOX 328 oWATONNA, MN 55060
ADDRESS OF INSURANCE CONIPANY
1899601 07 n1 t2024 - 07 t01 t2025
POLICY NUN,IBER
BRIAN ANDERSEN
EFFECTIVE DATES
25 BROAD ACRES FARM RD MEDWAY MA 029 50&686-6343
ADDRESS PHONE #
277 WHITES PATH SOUTH YARMOUTH, MA 02664
ENIPLOYER ADDRESS
EMPLOYER'S U'ORKERS' COMPENSATION OFFICER (IT ANY)
M EDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employmenr to fumish adequate and reasonable hospital and medical services in accordance uith the
protisions ofthe \f,'orkers' bompensation Act. Acopy of the First Repon of Injury musl be given tothe
injured employee. The employee may select his or her own physician- The reasonable cosl ofthe ser-
ui.., prouid.i by rhe trcating physician will be paid bv the insurer. if the treatment is necessary and
reasonably connected ro the work related injury. In cases requiring hospital anention. employees are
hereby noiified that the insurer has arranged for such attention at the
ADDRESS
I
HEALT
NAME OF HOSPITAL
TO BE POSTED BY EMPI-OYER I
NAME OF INSURANCE AGENT
DRYWALL\MASONRY SUPPLIES, INC.
DATE