HomeMy WebLinkAbout2025-26ch.No, 6d4ffi1q
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202512I)26 IIANDI-I\(; A\D S'I'ORA(;T] OI' I'OXI(] oR TIAT,ARDOTJS
I,ICENSI],\PPLICAl'ION
PI,EAST] COMPI,ETE 1'IIIS APPI,ICA'TION AND REI'URN I-I'WITH'TIIE LICI]
JUNE 30, 2025
-€'scilltED
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PI-IrAS I: COMPI.LTI: Al.l- QUI:S I IONS
NAME OF BUSINESS
I]USINIISS ADDRESS IN YARMOUTI I Q? urt tn ,q+ 0+? )X
BUSINESS TtsL. #o/O
/ Co,<l \',rnnu*h, L.1.4 0eG73
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Rt,ss I pach< M @ Ca11, ngl,o-tt/S Cam
MANA(;r:R (.oNr,\(.r ,,, ur,,,. f 7r5 ic-DiBloa,
fr,r-rrPlloNl, ii SOF' 8A2- ?OtO
R-EQUIBED owr'qln Nlrrae D?r/,,t Darti"aJ rett I -go/ -4tqo
so ff8 &8 ?Ozt
.4,T18 EIAE-S':E;.-
HEI'LTH DEFI
IIOME ADDRI]SS
CORPORATION NAMI] (IF APPLICABLE)E L.d ol'tLto
C0RPORATION ADDRF.SS E 4 + Fa// ttt'er ?ve .Rtcitrlrnl3.\u tk zB.letvcnr tt + 67771
MAlt.rNG ADDRESsl5|LLAtll Ltvct Alc &r,l4in1LSank-)R -\teDtnt- U,e 0s7+ I '-
IAX ID {FT..JN OR SSN)REer.rrRED 2b-Ofg,2S &G
t-lcllNSIls l{trN ANNLlAl.l.\' l.RoM .lt I )' I IO llr\l: r0. If IS \'otilt l{llsPoNSlllll-Il'Y 1.o I{I:'IURN
IIll:('0N{PI.l:'l llt).\Pl,l-l( A lloNls) \\l) Ii I I (.) [ ' I Ii I: I ) ll:l:(S)l]Y.,L,NI:10. IAIl-Ljl{h lo Do so wll-l-
Rlrsui f tNcl-ostiRl:()lr\'oL.l{I:SIr\llt-lSllMl:\.1 t.\'lll- l lll: Rt:QtiIRLD APPI-lCA l'loNs(s) AND
t,Lli(S)ARh RIrCtilVlil). A I.ll:ARIN(; IltlFORtl lllll ltOnRD OIr llLAt. lll MAY Bti RIIQUIRI,I) PRIOR
iious rlust be pair.l prior to rcoelval or issuarrce of your pcrmits. Plcase chcck
no_ nla_iown oi'r'arrnouih taxc
appropriately ilpaid: yc
r unl,J_
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuancc or renewal of any
license or pimrit to opcratc a busincss iIa person or company does not have a Certification of Workers Compcnsation
insurance. As part ol r.cncwal or issuancc ol'your pcmits. you must comPletc the encloscd Workers Compensation
Affidavit. If not applicablc, plcasc explaiu
REGISTRATION FORM SIGNI]D ,\NI) COMPI-E'IIID
CtllicK AND WORKITRS COMP AIIrll)Avrf I:NCLOSITI)
Al.t- SAFI:TY DATA Sl IlllIS ON I'll.li
l_
N
yN
AN}'NI.:W (:IIT,MI(]AI,S NTT]S'f B}: PRT..,\PPRO\'EI) B\'1'IIT] II},/\I,'I-II D}:PARI'MI]N'I''
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APPLICANT'S SIGNATURE
)DA'I'I]r a 2
MATLTNG
^DDRLSS
/547 Fe/ I !,t ycr-
to Rt'oPENlN(1.
The Commonwealth of Massachusetts
Deparnr ent of I n d u strial A cc i de nts
Office of I nvestigations
LafaYette CitY Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workcrs' Compcnsation Insurancc i\ffidavil: Gene ral Businesses
I'lcasc I'rint l-csiblv,\pplicant Inlormation
r)usiness/organ izarion Nan'tc:fEDll A* tOfA erh
naaress:/54V Fal/ 2tvr r 1Vt ?ttildtnT3,Jcrr
02#l Phonctt 774'9oi -4tuo
7J<s
Ciry/Statc/Zip
Arc/ou an cmplovcr? Chcck thc appropriatc box:
t.d Iu.aemployer *tn 44 . crnployccs (full andl
or pan-rims).*
usl ul]
5.
css'l'ypc (rcquired):
Rctail
RestauranL/Bar/Eating Establishinent
2
3
4
I arn a solc proprietor or partnership and have no
cmployecs working for mc in any capacity.
[No workers' comp. insurance required]
Wc are a corporation and its officcrs havc cxcrciscd
thcir right ofexcmption pcr c, 152.-Nl(4).andwchavc
no cmployces. INo workcrs' cotltp. insurancc rcr,1uircdl*
Wc are a non-prolit organrzalion. srallcd by voluntccrs'
with no ctnployccs. lNtt workcrs comp insttrancc tcq. I
lAny applicanl thal chccks box ill ntusr irlso lill out lhc scerrrrrr bclo$ showrng thctr *or
+*lf thc corporalc olliccrs havc cxcmptcd lhclil\cl!'c'. 'bll1 lh( corporilllon has olhcr crnpl
7. E Office and/or Sales (incl. real estate, auto, etc.)
Non-profit
Ilntertainment
Manufacturing
Icalth Carc
or"," j10,k f .-
kcrs cuurputsation policy inlonnation.
ovccs. u Nork('rs conlpcnsalion pollcy is rcquircd and such an
8.
9,
t0
t2
lrlsurancc Company Nantc:--Man ie
lnsurcr's Address
Crry/State/Zip;
Policy;r ol Scl
Atlnch a copl'
?D
f-ins.Lic.r 3tO18 l0L{(r9 ExpirationDate
o[ thc norkcrs' compensation policy dcclaratiolr pagc (showing thc policy numbcr and erpiration date).
liailurc to sccurc coveragc as rcquircd undcr 5 25A ot MGL c. I 52 can lcad to the irnposition of criminai penaities oi a tine up
to $ 1.500.00 and/o, on"-y.u. imprisonmcnt, as wcll as civil pcnaltics in the tbrm of a STOP WORK ORDER and a hne of up to
5250.00 a day against the \,iolator. llc adriscd that a copv ofthis statemcrt may be forwarded to the Oflce of lnvestigations of
thc DIA for insurance covcragc vcrtfication.
I o hcraby <ertili " und 1t?trultias ol perjuq tlnt th? i lbru ion provided tbove is trlte tnd coftecl.
g /aqlztSignaluLc
!ltoqc tt "f4'
qat 4tUo
OJficiul use only. Do not wrilc i,t this uret,lo be co pleted by citr* or tovtn olliciul.
Permit/Liccnsc #
I'hon c #:( 0ntact Prrson
('it\ or'l oYr n:
$\wv.mass,go\, 'dia
organiTaliorl should chcak bor /rl
l).rtc.
lssuing Authorit-Y (chcck onc):
tflnoaro of ttcatttr 2.!Building Departmcnt 3.8 Ciry/'I-own Clcrk 4.ELicensing Board
5[ Selcctmcn's office 6. Eother - _