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Home My WebLink About2025-26ch.No.tq24] PLEASE COI\IPLETE ALL QUESTIONS NAME OF BUSINESS BUSINESS ADDRESS IN YARMOUTHo MAILING ADDRESS )<,-,tt -- 8 H HN-2s-tgo7LICENSE FEE SI50 TOWN OF }'AR}IOUTH BOARD OF HEAI,TH 202512026 HANDLINC -\ND STORAGE oF TOXI(' O HAZ-A RDOUS M.{1'ERIALS LICE;\"SE APPI,ICATI CO}IPLETE THIS ,\PPI,ICATION A\D RTTUR\E\SE FEE BY JUNE 30, 2025 USINE gsi,{il::3 "7s-o\t1S (ou||1J RIOUIRFD MANAGER/CONTACT PERSON TELEPHoNE# 5ot lz<' al/'/ b. RFOUIRFN OWNER NAME HOMEADDRESS 499 fuE LY N.VAZMZVL tJ TEL,#1bk 7 7i-crytv CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS w L+< zy MAILIN(i ADDRESS )u."--- TEL. # 2rt>ao oLcTs rAX rD (FEIN on ssNl REOUIRED 0 Ll . 3bL.l g qb LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JIINE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORT THE BOARD OF HEALTH MAY BE REQI.NR-ED PRIOR TO REOPENING. Town of Yarmouth taxes and lignsmust be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yesj no- n a- Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewil ofany license or permit to operate a business ifa person or company does nol have a Cenification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Alfidayit. If not applicable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFEry DATA SHEETS ON FILE YN ANY NEW CHf,MICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION N APPLICANT'S SIGNATURE NEW APPLICATION- DATE 0,2 ic25 JUI EMAIL ADDRES S Nt2.....q"-(D Vo\,Aa^,t vat-. (on Z2 tlzlzs f\The Commonwealth of Massachusetts D epartm ent of I nd u strial A cci dents Olfice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ,fi Aoolicant lnformation Please Print Lesiblv Business/Organization Name:-tolr lac,e^*tc>^ Address 9BB kr,.ilc ?CYlo.rn :*'"*-* CirvlSrare/Zip:3 Phone #: 5)B -l.) 5 -oq t t{ Business Tvpe (required) ! netatt ! RestauranLtsar/Eating Establishment Office and./or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care_ . m shoiL 5. 6. 7. 8. 9. l0 lt t2 other I lrnz 'Ary applicaot that checks box #l musl also fill oul the section below showing their worten' compensation policy ioformation.t*Ifthe corporate officers have exempted themselves. but the corpomtion has olher employees. a workers' compensation policy is required and such an organization should check box #1. Are you an employer? Check the appropriate box: 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 arc a corporation and its officers have exercised their right ofexemption per c. 152. $l(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.] I 2 3 4 S t uln a employer with lO employees (full and/ I am an employer that is providing workers' compensation insurance for my employees, Belon' is lhe policf inrt)mration. Insurance C ompany Name /b i- lrlSu ra,nr,"- ko'r^Jr l3rnu' n lnsurer's Address Vt<-{-or CJ ?l Policv # or Self'-ins. Lic. #6sbztso-rtq1q/10 -o LS Expiration Date 3 Z Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Fai'lure to sccure coverage as rcquired under $ 25A of MGL c. I 52 can lead to the imposition 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 certify, un ins tnd penalties of peiury thal the informarton provided above is true snd correct. PL- Phone #: 5Dh I -tq - c.lq [q Official use only. Do fiot write in this area,lo be cornpleted b! ciy or tow olftcial. lssuing Authority (check one): 1fiBoard of Health 2.D Building Department 3f-'l Ciry/Town Clerk 4.flLicensing Board Permit/License # Phone #: 5E Selectmen's omce 6. Eother Contact Person: www.mass.gov/dia ciry/state/zip: Citv or Town: Information and Instructions Massachusetts Gencral Laws chaptcr 152 requircs all employers to provide workers' compensation for their employees Pursuant to this statute. an employee is defined as "...every person in the service of another under any contract of hire, 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 of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the rcceiver or trustec ofan individual, partnership. association or other legal entity. employing 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 thcreto shall not because ofsuch employment be deemed to be an employer." MGL chapter 152, $25C(6) also slates that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a busincss 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 I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for thc performance ofpublic work until acceptable evidence ofcompliance with the insurance rcriuircmcnts of this chapter havc becn presented to thc cor'ltracting suthority." 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 ofinsurance. Limired 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. 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 returncd to the city or town that the application for the permit or license is being requested. not the Depadment oflndustrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Dcpartment at the number listed bclow. Self-insured companies should enter their self-insurance license number on thc appropriate line. City or TorYn Offici.ls Please bc sure that the affidavit is complete and printcd legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations 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 pcrmit/license applications in any given year, necd 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 nuy be provided to the applicant as proofthat a ralid affidavil is on file for fuhrre permits or licenses. A new affidavit must be filled out each year. Where a home owner or cilizen 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 Offlrce of Investigations would likc to than] you in advance for your coopcration 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, MA 021I l-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7,,2019 www.maSS-gOv/dia EHUEE" INSURER: ACE AUERIC"IN INsuRANcE coMpANyA STOCR COMPANY 1. INSURED: VDAC woRKERs :iIPENsAnoN EMPLOYERS LIABIL'TY POLICY wpE AR INFORMAT|oN PAGE wc oo oo 01 ( A) POLICY NUMBER: ( 5s52rrB -4494p9 0 - o _ 2 s ) RENETA! oF ( 5s52IrB_44 gLEgo_o-24) NCC| CO CODE: 1215 s SOLIDAY VACATTON COIIIDOMI}ITEMS1188 RourE 28 $EST YAR!(OIrmi uA 02 673 PRODUCER: BROWN & BROIIN OP ![ASS !L5OO VTCTORY RDIIARINA BAY NORTE oullrcY MA 02 r.71 lnsured is A coRpoR f,TIOtI Other work places and identrfication numbers are shown in the schedule (s) attached.The policy period is tom 03_02_2s to 03_02_26 12:01 A.M. atthe insured's mailing address.A. WORKERS COMPENSATICcompensation r-aw ortne stlltl];y,Sflj:j Part one of the policv applies to the workers ![A FH!:H:lilffi'#H,'ffiiYffj:i"t;"!i1l:"":j,*" porrcvappries towork in each state risted in 2. 3. o: - B. c. 4. DATE OF ISSUE: OFFICE: PRODUCER: Bodily tnjury by Accident: Bodily tnjury by Disease: Bodily lnjury by Disease: 500000 Each Accidents00000 Policy Limit s00000 Each Employee $ s $ orHER STATES TN'URANCE: part rhree of the poricy appries to the states, rf any, risted hereCOVERAGE REPLACED BY EIIDORSEI(ENT WC 20 03 O5B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEUENTS . EXTENSION OF INFO PAGE The premium for this policy will be determined by our Manuals of Rules, classifications, Rates and RatingPlans. All required information is subi:ct to verm."tion "nJ lrrange by audit to be made eNNuALr,y. 02-28-25 sD RMD CHUBB 24Vr BROI|N & BROWN OF ![ASS LL r1213 77W2C ST ASSIGN: MA EH IJ E} EI" CLASSIFICATION SCHEDULE: CLASSIFICATIONS CODE NO VDAC WORKER,S COMPENSATION ANO EMPLOYERS LIABILITY POLICY TypE AR TNFORMATTON PAGE WC OO 00 01 ( A) POLICY NUMBER: ( 6s62uB -44 94p9 o - o - 2 s ) PREMIUM BASIS ESTIMATED TOTAL ANNUAL REMUNERATION RATES PER $1OO OF R,EMUNER,ATION ESTIMATED ANNUAL PREMIUM SEE EXTENSTON OF INFORI'ATION PAGE - SCEEDULE (S) SIC-CODE: ToLI NAICS: 7 2L199 TOTAI ESTIMA?ED .AXNUI,I STA}IDARD PREMTIN,T $PREIIIII,M DIscoI,NT O9OO-20 EXPENSE CONSTAITT TERRORISM TOTAT ESTTMATED PRE!4IN{ TAXES AND SURCIIARGES DEPOSIT AMOI'NT DI'E STANDARD 27 09 NONE 338 77 3L24 L25 3249!(P Minimum Ptemium: S 481 A/R (WcrP) # EMPLOYERS LIAAILITY !,ITNIMITM ! S 50 DATE OF ISSUE: 02.28-25 SD OFFICE: RUD ctIT,BB 24In PRODUCER: BROIIN & BROTIN OF MASS I,I, 77tI2C ST ASSIGNT MA EH IJ E].EI' INSITRER: ACE AIIERICAI INSITRANCE COMPAN.:a INSITRED ' S NAIT'E ! HOITIDAY VACATION CONDOIfINIITMS CLASSIFICATION CODE LOCATTON 00L 01 PEIN 043048145 ENTITY CD OO1 IIOLIDAY VACA?ION CONDOMIN IUMS 4 8I !,IAIN ST, RTE 2 I WEST YARMOUTH, MA 02673SIC CODE: 7011 NAICS: 721199 CARPENTRY . CONSTRUCTION OFRISIDENTIA.L DWELLINGS NOTEXCEEDING TITREE STORIES IN HEIGTIT WORKERS COMPENSATION AND EMPLOYERS LIABILIry POLICY EXTENSION OF INFO PAGE-SCHEDULE VIC OO OO 01 ( A) POLICY NUMBER: ( 6sE2uB _ 44 94p 9 o _ o _ 2 s ) 1215 s -MA R.ATE BUREAL IDT 0003d4081, 257 04s RATES PER 5100 oF REMT'NERA"ION ts- s545 I810 IF ANI IF AN':' 4.50 .04CLERICAL OFFICE EMPLOYEES NOC HOTEL ! ALL O?IIER EMPLOYEES & SAIJESPERSONS, DRIVERS 9052 1.09 2802 101214 DATE OF ISSUE:02-28-25 sD ST ASSIGN: MA PREMIInI BASIS ESTIITATED TOTAL ANNUAI REIITUNERATION ESTIMATED ANNUAI, PREMIIJU SCHEDULE NO: 1 OF MoRE EHUEsEI' wc wc wc wc wc wc wc wc ltc wc wc wc wc wc wc WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC OO O0 01 (A ) POLICYNUMBER: ( 5s G 2rrB -4,194p9 o - O - 2 s ) 00 00 00 00 00 00 20 20 20 20 20 20 20 20 20 00 00 00 00 04 04 03 03 03 03 03 04 04 05 06 001 001 001 001 001 001 001 001 001 001 001 001 001 001 001 OI. A01 A 01 A 01 A 14 0022c 01 0002A 03D 05 B 07 00 03 00 05 0001 A 04 00 INPORIIATION PAGE INFORMAUON PAGE 2 EXTENSION OF IIIFORUATION PT,GE - SCHEDI'I,E EIIDORS EMENT LISTING NOTIFICATION OE CHANGE IN OWNERSHIP ENDT TERRORISM RISK INS PROG REN,ITTH ACT ENDTMA LIMITS OF LIABII,ITI ENDORSEMEITT IIASSACEUSETTS - ASSESMENT CIIARGE MA NOIICE TO POI,ICYI'OI,DER ENDORSEMENT MA LIMITED OTHER STATES BENEFIT ENDT MA ASSIGNED RISK POOL ELTGIBILITYMA. CONST. CLASS PREM. AD". PROGRAM MASSACIIUSETTS PREMII'M DI'E DATE ENDTldA CANCETLATXOII ENDORSEMENT MA POLICY DEFTNTTION ENDT 101215 Page 1 of LAST LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE we agree that the forlowing risted endorsements form a part of this poricy on rrs efiective date. DATE OF ISSUE: 02-28.25 STASSIGN: MA