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Home My WebLink About2025-266L \6q Lr.ENSEFEEs,50 Fill.lM-a<- 19fu I TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING A.\D STORAGE OF TOXIC OR HAZARDOUS I\IATERIALS LICENSE APPLICATION CO:\IPLETE THIS APPLICATION AND RETURN IT }I'ITH THE BY JUNE 30. 2025 PI-I'ASE CONIPI-ETE ALI- QT'ESTIO\S NAME OF BIJSINF]SS BUSTNESS rEL. #HqAbrff BI.JSINESS ADDRESS IN YARMOUTH MAILING ADDRESS REEEihIEB I lil 'n r o+tl- o6 13 6.r3 REOU I RED I!trANAGER/CONTACT PE ON RFoLIRFD OWNER NAME crJ{v BLor.I:. ( TEL,#4ot.4Tl-o(,q I HOME ADDRESS \ oq ("L ^/t.6!1e l{vavrni ( o26ol,- CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TEL. # MAILING ADDRESS 6 l: LICENSES RTIN ANNUALLY FROM JULY I TO JTNE 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 LINTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECETVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENTNG. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yes 4.,/ 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 person or company does not have a Cenification of Workers Compcnsation insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affidavit. If not applicable. pleasc explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK-ERS COMP AFFIDAVITENCLOSED ALL SAFETY DATA SHEETS ON FILE yN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION ,.'/ NEW APPLICATION- )Z Y__\/-N APPLICANT'S SIGNATURE DATE tl - lcvvaP a\ a I ^,-ro EMAIL ADDRESS TELEPH0NE# qo8. 4+l- OC65q f\ o..r o rr c.l D .,b\ .\r TAX ID (FEIN OR SSN)BS(LUIBE.D The Commonwealth of Massachusetts Departm ent of I n du strial A cci de n ts Ofjic e of I n v e s ti g ati o n s Lafayeue City Center 2 Avenue de Lafayette, Boston, MA 0211I-1750 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses [) E i:/ Applicant I nformation Please Print Legitrlv Business/Organization Name: D \ pT I LL a nR A ECo\.lo Lo t) (TE . Address: City/State/Zip:b+Phone#: 5, ot^T1-l-c 6tct 'Any applicant that checks box #l must also fill out the section below showing their workers compensation policy informati *ilfthe corporate officers have exempted themselves. but the corporation has other employees, a workers compensation policy is required and such an organization should check box #1. 2 3 4 I am a sole proprietor or partnership and havc no cmployees working for me in any capacitl. [No workers' comp. insurance required] We are a corporation and its officers have cxercised their right of exemption per c. 152, $ l(4), and we have no employees. [No workers' comp. insurance required]* Wc are a non-profit organizalion, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Are vou an enrplol'er? Ch box:eck a ro teppp employees (full and/l. ffl am a employer with or part-time).+ Business Type (required): 5. E Retail 6. E Restaurantr Bar/L,ating Establishment 9. ! Entertainment 10.! Manufacturing I 1.! Health Carc Oflice and/or Sales (incl. real estate, auto, etc.) Non-profit \,f-'ll 1 8 n.@other I am tn employer that is p Insurance Company Name Insurer's Address City/State/Zip Policy # or SeIt'-ins. Lic, # roviding workers' compensotion insurunce for my employees. Bekv is the policy informotion., .L \'^<".U I vr<u"eo,rrr,, forrr,q'uu /R t.t l"r r. h fT (1 6- \.4 o Expiration Date tr/tt" /lttso Attach I copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secue coverage as required under g 25A ofMGL c. 152 can lead to the imposition of crimrDal penalties ofa fine up to $1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day againsl the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebl' certify, under the pains ond penolties ofperjury that the infornrution pruided dbove is true and correct. Si ture Phone #: qcb 1 + \. 66gq Datc t\vb Olficial use only. Do not t'rite in this urea, lo be completed by ciry or town oJficiol. lssuing Authoritv (check one): I[BoardofHealth 2.EBuildingDepartment 3.ECiry/To$nClerk Permit/License # 4.ELicensing Board Citv or Town: 5[ Selectmen's Office 6. Elother Conlact Person: www,mass,gov/dia the Phone #: Information and Instructions Massachusetts General Laws chapter 152 requircs all cmployers to providc workers' compensation for their employees. Pursuant to this statnle, at employea is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written." An employer is defined as "an individual, pannership. 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 trustee ofan individual, partnership, association or othcr lcgal cntity, cmploying employees. However. the 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 thercto shall not becausc of such cmploymcnt bc deemcd to be an employer." MGL chapler 152, g25C(6) also states that "every stat€ or local licensing agency shall withhold th€ issuance or renewal of a license or permit to opcrate a busincss or to construcl buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for thc pcrlbrmancc ofpublic work until acccfrlablc cridcncc ofcomoliance with the insurancc requircmcnts of this chaptcr have been prcscnted to the contracting authority." Applicants Please fill out the workers' compensation aflidavit 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 of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. lf 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 of insurance coverage. Also be sure to sign and date the alfidavit. The a{Tidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Oflicials Please be sure that the affidavit is completc and printed legibly. The Depanmenl has providcd a spacc at the bottom ofthe affidavit for you to fill out in the event the Office of lnvestigations has to contacl you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiVliccnse applications in any given ycar, nccd only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prooi'that a valid at'ildar,it is on irle lbr luure permits or hceuses. A new allitlavir must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or pcrmit to bum leaves etc.) said pcrson is NOT required to completc this affidavit. The Office of Investigations would like to thanl you in advance for your cooperation 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, MA0211l-1750 Tel. (857) 121-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 www.mass.gov/dia