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NAME OF BUSINESS Ef.r,.J,nslo*l 0v..!$to.h-
LICENSE FEE S I50 -tq0
TOWN OF YARMOUTH BOARD OF HEALTH
202512026 HANDLING AND STORAGE OF TOXIC OR HAZAR.DOUS MATERIALS
LICENSE APPLICATION
COMPLETE THIS APPLICATION AND RETURN IT WITH
BY JUNE 30, 2025 /..\ss tijl=-(e rEnn::
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BUSINESS TEL,
BUSINESS ADDRESS IN YARMOUTH AI FW4^ A..^{- Sq"* *:J'r(II*.,T11, O>\b\
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CORPORATION NAME (IF APPLICABLE)!'nsttr a tlu TEL.# 6riv.lql-17?8
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MAILING ADDRESS Sonat-
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EINTAX tD R ssN)[tEQULX{&D 11.-{ -.?Yr -tt\ 3
LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR R.ESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JTINE 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 REQTJIRED PRIOR
TO REOPENING.
Torvn of Yarmoulrr taxes and liens must be paid prior to renewal or issuarce of your penaits. Pleasc check
appropriately ifpaid: yes r/ no_ nta-
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yannouth is required to hold issuance or renewal ofany
license or pennit to operate a business ifa person or company does not have a Certification of Workers Compensation
insurance. As part ofthe renewaI or issuance ofyour permits, you must completc the enclosed workers
Compensation Affidavit. lf not aDplicable, please explain:
REGISTRATION FORM SICNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ONFILE
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NANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT.
RENEWAL APPLICATION
APPLICANT'S SIGNATURE
NEW APPLICATION
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