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Home My WebLink About2025-261d3C H1'T!.3H 9Z0Z I Z Nnt ,i?029m5:HAN 0h-ilo- aa{s LICENSE FEE SI50 8HH.1-/-23-/8q/ TOWN OF YARNTOUTH BOAR.D OF HEALTH LING ,{ND STORACE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION( ONIPLETE TH ls APPLICATION ,\N D RETLIR-\.- lT \\'lTH THE LlCENsll FEU PLEASE CONIPLITE ALL OUESTIONS €scmiu TNESSTEL.# to?-7 7{' {5?5 BY JUNE 30. 2025 H*eNAME OF BUSINESS1 BUS BUSINESS ADDRESS IN YARMOUTTI 3oo 14 ,1 {2d . I ( ,r 9D hw*-Ts f/4"0 /wt^9 tv|* ozolzMAILING ADDRE EMAIL ADDRESS BEQIIBED MANAGER/CONTACT PERSON TELEPHoNE # q t, /s-' 591 S RT'OI I R}]N OWNER NAME I HoMEADDRESS 310 CORPORATION NAME (IF APPLICABLE) @ ,eiu\ A.rEL# rot-J /44) .L" dof -7 ),i-ftlr v / v coRPoRATToNADDRESS 3o h MAILING ADDRESS hDl.tt v D /-hr oq - 2{ ol ozs otb'J j LICENSES RLIN ANNUALLY FROM JULY I TO JUNE ]0. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQTNRED 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 RECEN'ED. A HEARING BEFOR-E THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately if paid: yes_/ no- ala- 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 pcrson or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits. you must complete the enclosed Workers Compensation Alfidavit. If not applicable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE Y L_T N ;fr",,,^*,L.,.ANY NE\\' CHEMICALS }IUST BE PRE-,{PPROVED B}' THE APPLICANT'S SIGNATURE,'-fff *,to* L6i'..12 oel;*,lhrlA I )Lpff c, )^ rAx rD(FEIN on ssNlRE@IBED RENEwAL applrcarroN irl NEw AppLICATIoN The Commonweahh of Massachusetts D epartme n t of I n d u str ial A cci d e n ts Ollice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses licant Information Business/Organization Name: Address: City/State/Zip: Please Print L bl ltt ' 'l Are you an employer? Check the appropriate box: 1.ffi I am a employer u'ith or part-time).* employees (full and/ 2 J 4 I am a solc proprietor or partnership and havc no employees working lor 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]*r We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone#: *k11i6 15 Business Type (required) Retail Restaurant/Bar/Eating Establishment Office and/or Sales (incl. real eslate, auto, etc.) 5 6 7 8. ! Non-profit 9. l0 Entertainment Manufacturing I l.! Health Care t2.fi other Loolo mt4/tLnL 4erud tAny applicant thal chccks box #l must also fill out the section below showing their worke6' compeosation policy informalion.**lftle corporate officers have exempted themselves, but the corpomtion has olher employees. a workers' compensation policy is requited and such an organization should check box # I . I am an employer lhat is providing workers' compensqtion insurqnce for my euplol'ees. Bekn' is the policf infornalion. Insurance Company Insurer's Address: Name Lrte 471 tgtn Na..Lud Sl4{e+q0b Policv # or Selt'-ins. Lic. #A S bLUB - 1111P10-l-2,5 r*piration Date o7- tt - 2L 9* do hereby certify,under the pains tnd penalties ofperjury that the information provided abow is true and coftect.I S ILe Ttnl o,rrDA dur,* e 22A1.[)ulcture #:6 onD. Official use only. Do not write in this area, lo be completed by city or to$'n otrtci . Permit/License # Phonc #; 3.E City/Town Clerk 4.ELicensing Board lssuing Authority (check one): lflBoard of Health 2.! Building Department 5[ Selectmen's Office 6. Eother Contact Person: www.mass.gov/dia Cityi 5121"77i0' 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 lcad to thc imposition ofcrinrinal peualties ofa finc up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the tbrm of a STOP WORK ORDER and a tine 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 veriltcation. Citv or Tou'n: Information and lnstructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this statute, an employee rs 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 olthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the receivcr or trustee ofan individual, partnership, association or other legal entity, cmploying cmployees. However. thc owner ofa dwelling house having not more lhan three apanments and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainlenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not becausc of such emplo;.rnent bc deemed to be an employer." MGI- chaprer 152, g25C(6) also stales that "every state or local licensing agency shall withhold the issuance or rencwal of a license or permil to opcratc 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 I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work unlil acccptable evidence of compliance with the insurancc rcquircments of this chaptcr havc bccn prescntcd 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 ofinsurance. Limited Liability Companies (LLC) or Limitcd Liability Partncrships (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 affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial 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 listcd below. Self-insured companies should enter their self-insurance license number on thc appropriate line. City or Town Officials Plcase be sure that the affidavit is complete and printed legibly. Thc Department has provided a space at the bottom of the affidavit for you to fill out in the event the Officc of lnvcstigations has to contacl you regarding the applicant. Please be sure to fill in the permit/license number which will be txed as a reference number. ln addition, an applicant that must submit multiplc permiVlicensc applications in any given year, need only submit one affidavit indicating cunent policy information (ifnecessary). A copy of the afiidavit that has been officially stamped or marked by the city or town may be provided to the applicant rs proofthal a valid aftiJavil 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 relaled 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 alldavit. The Office 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-S77-MASSAFE Fax (617) 727-7749 Form Revised ?,2019 WWW.maSS.gOV/dia EHIJE}EI' VDAC WORKERS COMPENSATION AND EMPLOYERS LIABILIry POLICY TYPE AR IhJT'ORMATION PAGE WC OO OO 01 ( A) POLICY NUMBT:R: (6s52vB- 441 7P7 o - 6 - 25]- RENEWAT Ori l6S62UB - 44 7 7 p'lO - 6 - 24) NCCI CO CODE: 1216 s 1. INSURED: HORSE POND CORP DBA IIALCYON CONDOMINIIJMS 3OO BI'CX ISL.AND RD I{EST YARMOUTH MA 02573.2590 HILB GROI'P OI :IE LLC 973 IYANNOUGi| IOAD, 2ND PO BOX 1990 HY.ANNIS MA O2']1 INSURER.: AcE AMERICAN INSURANCE CoMPANY A STOCK COMPAIiIY PRODUCER: FL Insured is A coRPoRATroN other work places and identmcation numbers are shown in the schedule(s) attached. 2. The policy period is from 02-L4-2s Io 02-1,4-26 12:01 A.M. atthe insured's mailing address 3. A. WORKERS COMPENSATION TNSURANCE: Part One of the policy applies to the Workers Compensataon Law of the state(s) listed here: MA B. EMPLOYERS LlABlLlry INSURANCE: Part Two of the policy apDlies to work in each state listed in item 3.A. The limils of our liability under Part Two are: Bodily lnjury by Accident: g 1000000 Each Acci:'er,t Bodrly lnjury by Disease: S 1000000 Policy Limi Bodily lniury by Disease: S 1000000 Each Emplolee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, rf any, listed here COVERAGE REPLACED BY ENDORSEMENT WC 20 03 O5B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSE!,IENTS - EXTENSION OF INPO F.1GE 4. The premium for this policy will be determined by our Manuals of Rr le i, Classifications, Rates and Rating Plans. All required anformation is sublect to verification and change b)'audrt to be made lNtlox,r,v. DATE OF ISSUE: OFFICE: PRODUCER: : 9500 0L-23-25 WC RI'D CIII'BB 24U HILB GROUP OF NE LLC 7 3M2v ST ASSIGNT [tL