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Home My WebLink About2025-26trlr.lt/r. l167 BHur-r -2{- 3bLICENSE FEE S I50 TO\TN O}- }'AR}IOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDO LICENSE APPLICATION COMPLETE THIS APPLICATION AND Rf,TURN IT WITH TH BY JUNE 30. 2025 PLEASE CONIPT-E ALL OUESTIONS NAME OF BUSINESS BUSINESS TEL. # BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESSUO!.t Chr.<. EMAIL ADDRESS c s TELEPHoNE T Q18 36\' l.L?J- N RT]OUlRFN OWNER NAME N TEL,#9ze 32f.4't2r S NBE€EIMTED rrc.qyls0,AEHZ5 BEGEOVED JUL U,/, ?OZ5 HEAITH DEPT I IOME ADDRESS o CORPORATION NAME (IF APPLICABLE) coRPoRATToNADDRESS -9.i.<- o z TEL. # tr..e MAILING ADDRESS .5*r-,.c- rAx rD (FErN oR ssNrBE@.IED 33- SS1cl7 .11 LICENSES RTIN ANNUALLY FROM ruLY I TO JT]NE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILTIRE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT IINTIL 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 taxcs antl,lie appropriately if paid: yes /ns must be paid prior to renewal or issuance ofyour permits. Please checkno n/a Under Chapter 152, Sec. 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed workers Compcnsation Affidavit. If nor licable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK-ERS COMP AIFIDAVIT ENCLOSED / Y, NALL SAFEry DATA SHEETS ONFILE I' YNANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION- NEW APPLICATION / APPLICANT'S SIGNATURE RF OLIRED MANAGER/CONTACT PERSON HEAITH DEPT. DATE: 7.1. L{ & Applicant Information Plcase Print l,eeibly Business/Organization Name: Address: lZ37 R.r".tP "*Ciryi Stare/Zip :SO Business Type (required): 5. E Retail 6. ! Restaurant,tsarlEating Establishnent 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing I I .! Health Care D.dother f,lprl *Any applicant that checks box #I musl also fill out the section below showing their workers compensation policy information.**lf the corporate office$ have exempted themselves. but the corporalion has other employees, a workers' conrpensation policy rs required and such an organization should check box #1. Are you an employer? Check the appropriate box: t.d tu a employer oitn 3 employees 1full and' or part-time).+ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4), and we have no employees. [No workers'comp. insurance required]* We are a non-profit organization, staffed by volunteers, with no employees. [No workers'comp. insurance req.] 2 -) 4 I am tn employer thal is providing workers' compensttion insuroncefor my employees, Below is the policy information. lnsurance Company Name: fl.r-, &{3..&:} 6rLL lnsurer's Address: )LOO r Jts.er^.^d Ctf^ A Sr'sl |u..Jta.o+o fK 1gcity/slate/zip: Policy # or Sel Attach a copv f-ins. Lic. #ak 08 \NEr- gRSu-IL Expiration Date of the workers' .rGpJn*-tion policv declaratio n page (shorving the policv numbe r and expirat at€). Failure to secure coverage as required under $ 25A of MGL c. I 52 can lead to the irnposition of criminal penalties of a 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 against 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 hereby certdy, undet the po ins ondpenalties of perjury that the information provided aboye is true and correct. Si -1-7-t Phone #: qrc 3U1'ILZL lssuing Authority (check one): I flBoard of Health 2.! Building Department 3.[ Ciry/Town Clerk Permit/License # 4. E Licensing Board Phone #: City or Town: 5[ Selectmen's Oflice 6. lother Contact Person: www.mass.gov/dia The Commonwealth of Massachusetts D epartm en t of I n d u strial Acci de nts Offi c e of I nv es ti g at i o n s Lafayette City Center 2 Avenue de Lafayelte, Boston, MA 02111-1750 b'ww.mass,gov/dia Workers' Compensation InsuranceAffidavit: General Businesses Phone #: D Olficial use onll'. Do not brite it, this area, to be completed by ciq or nwn olficiol. Information and Instructions Massachusetts General Laws chaptcr 152 requircs all cmployers to provide rvorkcrs' compensation for their employees Pursuant to this statule. an employee is defined as "...every person in lhe service ofanother under any contract ofhire. express or implied, oral or written." MGL chapter I 52, g25C(6) also stales that "every state or local licensing agency shall withhold the issuance or renewal of a liccnse or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cntcr into any contract for thc performancc ofpublic u'ork until acceptable cvidence ofcompliance with the insurance requirements of this chaptcr havc bcen prcscnted to thc contracting authority." City or Town Oflicials Pleasc be sure that the affidavit is complete and printed lcgibly. The Departmcnl has provided a space at the bottom of thc affidavit for you to fill out in thc cvent thc Office of Investigations has to contact you rcgarding 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 pcrmiVlicense applications in any given year, nced only submit one affidavit indicating cunent policy information (if necessary). A copy of the affrdavit that has been oficially stamped or marked by the city or town may bc provitled to rhe applicant as prooi that a vaiiti .,iiiri,r it is on fiic for iuturc permits or licenses. A new affidavrt 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 permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Oflice of Investigations would like to thank 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 Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA021l1-1750 Tel. (857) 321-7406 or 1-S77-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 www.mass.gov/dia 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 trustee ofan individual, partncrship, association or othcr lcgal entity, cmploying employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maint€nance. construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment bc deemed to be an employer." Applicants Please fill out the workers' compensation affidavit 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 Limitcd Liability Partnerships (LLP) with no cmployees other than the members or partners, are not required to carry workers' compensation insurance. Ifan 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 covcrage. Also be sure to sign and date the aflidavit. The affidavit should bc 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 Dcpartment at the number listed below. Self-insurcd companies should cntcr their sclf-insurance license number on thc appropriatc line.