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Home My WebLink About2025-26)o ch. Mr. tO76 LICENSE FEE S I50 8HH/1,/- Ztf - 28 TO\\'\ OF }'AR}IOUTH BOARD OF HEALTH 202512026 H,-\\DLI\C.\\D STOR,\GE OF TOXIC OR HAZ-ARDOUS NT.\TERIALS LICENSE APPLIC,4TIo}.. CO}IPLETE THIS APPLICATION AND RETT'R\ IT \\'ITH THE LICENSE FEE BY JUNE 30, 2025 PLEASE CoMPLETEALL OLIESTIoNS fn\,{,t.) 56UYH Vrlz{n4vfi( b6.t. NAME oF BTJsINEss IYT CS k_ €s . | 1.. f- t irirtrlD BI ISINI.,SS Tt.]I, f k 0t/o qS&S aa Aovrc 2K rtr"nrHa YvrY! 6zal4BUSINESS ADDRESS IN YARMOUTII vArLrNG ADDRESS 5 xtyrz EMAIL ADDRESS n /lL Rr'ol ]l RF D HoME ADDRESS owNEnN,4vEJohr.,, .).0.1..a= 3+- . IESS q'? 3V'.l>r< siAe -bru"..,< 3. rct* 5lr ' )'bO -1rcL1'l vlrYf17rJv\ozaql L(L'vi ( BEI]LIBED, MANAGER/CONTACT PERSON Lrt^- V TELEPHoNE t \DY'\bo" q<V{ CORPORATION NAME (IF APPLICABLE)-TEL. # CORPORATION ADDRESS MAILING ADDRESS fip - ego'?i+t{G LICENSES RUN ANNUALLY FROM JULY I TO JLINE 30. IT IS YOUR RESPONSIBILIry 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 RECETVED. A HEARINC BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town ofYarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yes-- no_ nla- 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 Ccrtification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits, you musl complete the enclosed Workers Qqmpgq141lon Affidavit. lf not applicable, plelLse explain: REGISTRATION FORM SIGNED AND ('OMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE /2 Y N N APPLICANT'S SIGNATURE DATE aa\ab rAX rD (FEIN oR ssN)BpUIBED ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE Hf,ALTH DEPARTMENT. RENEWAL APPLICATION NEW APPLICATION Business/Organization Name fni,rri gOrvr Lplrr,tyrzvtrt -]>rga- {rrashz\z=-U vr N1- .J Address:AX Lo r'\ CitylStatelZip ,3 Are v u an employer? Check the appropriate box: I I am a employer with or part-time). + employees (full and/ 2.2 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 ils officers have exercised their right of excmption 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 employecs. [No workers' comp. insurance req.] 4E (l L4 Phone#: 5D(' lbO-tlfK{ Business Type (required): 5. ! netait 6. ! Restaurant/Bar/Eating Establishment '7. 8. 9. l0 ll O{fice and,/or Sales (incl. real estate, auto, etc.) Non-profit Entertaiffnent Manufacturing Health Care ndotne *Any applicant that checks box # | must also lill out the section below showing their workers' compcnsation policy information.**lfthe corpordte officers have exempted themselves. but the corpomtion has other employees. a workers' compensalion policy is required and such an organization should check box #1. roviding workers' compensolion insurqncefor my employees. Below is the policy inlormolion.I am an employer thal is p lnsurance Company Name lnsurer's Address: S-f 'I-n,,z,r C+r.- 'L-( I City/State/Zip Policy # or Se vr tr. OI{OZ 4-o rf-ins. Lic. # NOLDD Fe!39.q ,O}S A Expiration Date o ar Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A of MGL 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 lorm 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 lnvestigations of the DIA for insurance coverage verification. I do hereby certify, under the pains ond penalties of perjury that the information provided aboye is true and correcl Signature:qx\A-Date: b I Is- Phone #: 5D V' ltoo \ss{ OlJicial use only, Do not t rite i this ares, to be completed by ci,' or town officia!. Phone #: 3.8 Ciry/Town Clerk 4.ELicensing Board Issuing Authoritv (check one): lflBoard of Health 2.ElBuilding Department5f] Selectmen's Office 6. Eother Contact Person: wx,rr.mass,gov/dia The Commonwealth of Massachusetts Departm ent of I n d u strial A ccidents Ofli c e of I n v e s ti g ati o n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant lnformation Please Print Lesibly Permit/License #Citv or Ton n: Information and Instructions Massachusetts General Laws chapter 152 requircs all employers to providc workers' compensation for their employees Pursuant to this statfie. an employee 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, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enlerprise. and including the legal representatives ofa deceased employer, or the receiver or trustee ofan individual, partnership, association or othcr legal entity, employing employees. However. thc 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, conskuction or repair work on such dwelling house or on thc grounds or building appurtcnant thereto shall not because of such employment be deemed to bc an employer." MGL chapter 152, $25C(6) also states that "€ver) state or local licensing agency shall withhold th€ issuance or renewal of a license or permit to opcrate a business or to construct buildings in the commonwealth for any applicant who has not produced acc€ptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, g25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract for the performancc of public.,rork until acceptablc cvidence ofcompliance with the insurance requiremcnts of this chaptcr have bccn prescnted to thc contracting authority." 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 Limited Liability Partncrships (LLP) with no employees othcr than the membcrs 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 Departmenl of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 ifyou 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 thc appropriate line. City or Town Oflicials Please be sure that the afTidavit is complete and printcd legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the evcnt the Office of Invcstigations has to contact 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 permiVlicense applications in any given ycar, need only submit one aflidavit indicating cunent policy information (if necessary). A copy of the affidavit that has been oflicially stamped or marked by the city or town may be provided to the applicant as proofthat a va[d aftidavit is on file for future permits or licenses. A new affidavit 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 aflidavit. The Oifice 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 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02l11-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 712019 WVw'mass'gov/dia WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers lnsurance Company (500) 54 Third Avenus, Burlington, MA 01803{970 (800) 876-276s 40959 wcc-500-8243569-2025A ITEM1. The lnsured: MLW South Yarmouth LLC DBA: Mailino Addresst 822 Route 28- South Yarmouth, MA 02664 Legal Entity Type: Limited Liability Company (LLC) Other workplaces not shown above: See Location Minimum Premium: $320 GOV STATE GOV CLASS 9058 This policy, including all endorsements, is hereby muntersigned by FEIN: '.'-'3746 2. The policy period is from: 05/05/2025 f o 0510512026 1201 a.m. at the insured's mailing address 3. A. Workers Compensation lnsurance: Part One of the policy applies to the Workers Compensation Law of the states listed here MA B. Emptoyers Liability lnsurance: Part Two of the policy applies to work in each state listed in ltem 3.A. The limits of our liability under Part Two are: Bodily lnjury by Accident $1.000.000 each accident Bodily lnjury by Disease S1.000.000 policy limit Bodily lnjury by Disease $1.000.000 each employee C. Other States lnsurance: Part Three ofthe policy applios to the states, if any, listed here: Coverage Replaced by Endorsement WC 20 03 06 B D. This policy includes these endorsements and schedules: SEE ScHEOULE The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classitications Pramium Ba3is Rates Total Estimated Per Estimatedcodo-::- Annual $100 of AnnualNo Remuneration Ramuneration Premium SEE CLASS COOE SCHEDULE 4 Total Estimated Annual Premium Deposit Premium State Assessments/Surcharge $7,492 $1,952 $317 '1 :' '- 5t8t2025 Authorized Signature Service Office:P.O. Box 4070 aurrinqton. MA 01 803{970 The FaiMay Agency LLC 944 WASHINGTON STREET SOUTII EASTON, MA 02375 wc 0o 0o 01 A (Ed.7-11) lncludes copy.Ehted matetial ofthe National Council on Compensation lnsurance, lnc., us€d with its permission. page 1 of I Date NCCr NO: Poliry No. Prior Policy No.