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Home My WebLink About2025-26c\L lotb\3 LICENSE FEE $ I50 BHIjX,r az- lr.ia TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE O['TOXIC OR HAZARDOUS N{ATERIALS LICENSE APPLICATION RECEIyTn CONIPLETE THIS APPLICATION AND RETURN IT WITH THE LICEN.SFfTE BY JUNE 30, 202s li jtl I 5 ?C,?\ PLEASE COMPLETE AI,L QUESIION,S NAME oF BUSINESS f/yortn'i /t)arrtta l,tc' BUSINESS ADDRESS IN YARMOUTH HEALTH osc BusrNESs rEL. o 6os) -71o' qoo1 tJ, /ar,.to A h,1 otc73n MAILING ADDRESS / lr/,'//oQ $1 ,5 a_/o/ EMAIL ADDRESS c I a .1 BEqUIBED MANAGER/CONTACT PERSON Joe 5.,fA ss TELEPHONE * ({ot; ??o - yooo x/46 vr\rllrb B,EOLIE.EI} OWNER NAME Ut-kurkzr rE,.* (sos) 21e:leee r/30 HOME ADDRESS sl fia ooliq A/c (ca/r. vr //t /A/t CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS rEL. MAILING ADDRESS TAX ID (FEIN OR SSN)REOUIRED Oq.ILXOA6 LICENSES RUN ANNUALLY FROM JULY I TO JL]NE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQTIIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOTIR 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 of Yarmouth taxes andfens must be paid prior to renewal or issuance of your permits. Please check appropflatel) ifpaid: yes_A!_ no_ 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 Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Aflidavit. If not applicablc, Dlease explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK-ERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE YN AIIY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION / NEW APPLICATION- NY APPLICANT'S SIGNATURE 5a,"c DArE: a/rc/zr The Commonweolth of Mossochusetts D epartm ent of In du strial A ccide n ts Ofjice of I nvestigatio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name Address: I VilboJ 5r r(,Qan)ta .Zn Are y2u an employer? Check the appropriate box: t. EI t am a employer with (t employees (tull and/ or part-time ). * 2. E I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. E we are 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]** 4. I We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] CitylSratelZipl 60/t(s lflfl ()Phone #:6og) 77o- q2sp Business T1'pe (required) Retail Restauranf,/Elar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment M anufacturing Health Care Other fitll SctvtZc /0o.'Ao. 5. 6. 7. 8. 9. l0 ll t2 g *Any applicanl that checks box #l must also fill out the seclion below showing thcir workers compensation policy information.**lf the corporale officers have exempted themselves. but the corporalion has other employces. a *orkers compensalion policy is required and such an organization should check box #1. I om an employer th Insurance Company at is providing Name: t'l workers' compensalion insuronce lor my employees. Below is the policy inlormuion. ^/tovor Tnsdfaocc coa Insurer's Address: P 0. ,tOo LIS (hurlcflc tt/C Policy # or Self-ins. Lic. #v)il LqTgd€to Expiration Date tlt/20 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failurc to secure covcrage as rcquired under $ 25A of MGL c. 152 can lead to the imposition ofcrinrinal 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 Ofhce of lnvestigations of the DIA for insurance coverage verification. I do hereby certify, under the pains snd pendties of perjury thal the information provided above is true and correct. Si nalure Date: 6 /3 7+ Phone #s) ??o-qooo Y //6 Ofiicial use only. Do ttot h,rite in this area, to be completed by city or town o!/icia!. lssuing Authority (check one): lfiBoard of Health 2.! Buitding5[ Selectmen's Ofiice 6. Eoth€r Contact Person: Department 3.E City/Town Cl€rk 4.ELicensing Board Permit/License # Phone #: www.mass.govldia Applicant Information Please Print Legibly City/S1s1gr71p' City or Town: Information and Instructions Massachusetts Gcncral Laws chapter 152 rcquircs all cmployers to providc workcts' cornpcnsation for their employecs. Pursuant to this stat e, an employee is defined as "...every person in the service ofanother under any contract ofhire. r' express or implied, oral or written." An employer rs 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, partnership, association or other legal entity, employing employees. Howevcr, the owner ol'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 maintenance. construction or repair work on such dwelling house or on thc grounds or building appurtcnant thcreto shall not becausc of such employment be deemed to bc an employer." MGl, chapter 152, g25C(6) also states that "€very state or local licensing agency shall withhold the issuance or renewal of a licensc or permit to operatc 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, MCL chapter I 52, S25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract for the pcrformance ofpublic work until acccptable evidcnce of compliance with the insurancc rcclu;rcrrcirts of thi: citapter huvc t)u('ri prcsallic\i io rlr! !():iliiictiiiB authoiil;." City or Town Officials Please bc sure that the affidavit is complete and printcd legibly. The Department has provided a space at the boftom of the affidavit for you to fill out in the evcnt the Office of Investigations has to contact you regarding 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 permit/license applications in any given year, need only submit one affidavit indicating cunent policy information (if necessary). A copy of the affrdavit that has been officially stamped or marked by the city or town rna,v be pror:iCed to the applicant as proofthat a .-'alid affidavit is on file for firhrre permiLs or licenses. A nerv affidevit must be filled out each year. Where a home owner or citizen is obtaining a license or permil 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 Office of tnvestigations would like to thank you in advance for your coopcration and should you have any questions, please do not hesitate to give us a call. Applicants Please lill 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 of insurance. Limited Liability Companies (LLC) or Limitcd 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 thal this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumcd to the city or town that the application for the permit or license is being requested. not the Depanment oflndustrial Accidents. Should you have any queslions regarding the law or ilyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter thcir self-insurance license numbcr on the appropriate line. 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. MA02l1l-1750 Tel. (857) 321-'1406 or l-877-MASSAFE Fax (617) 727-7'749 Form Revised 7i2019 www.mass'gov/dia