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Home My WebLink About2025-26C\L\aqtb Lrcr,NSr- Fr:r, sr5o DLI HM - a3- \8q b TOWN OF YARMOUTH BOARD OF HEALTH 2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZAR,DOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BYruNE30,202s RECE|VED PLEASE COMPLETE ALL OUESTIONS NAME OF BUSINESS I'ttr s't"f r ll"t-l Cenf<r BUSTNESSADDRESSTNyARMouTu'l Y'l !wr,t rl JUN 2 0 2025 G So,-7 I | !tt'rvAhris DV-fltfpf[r[$p1sr-. + ptE MAILING ADDRIJSS EMAIL ADDR,ESS /h ) kettton Q Gf*;t - c,,n RgquBED. MANACE R/CONTACT PERSON 1,,/ tl so ,! Al mtil a TELEPHONE #Sof-16f-\t)-77 RFOUIREN OWNER NAME h ithotl fI, Dcn TEL,#5og 'zcY't?rr HoMEADDRESS )X (0",a P"l [,f rreTtwt/l,vf ol/tt CORPORATION NAME (IF APPLICABLE)fh e &f-'y fonn.qra- BC ss. # to3'763'LY'r coRPoRATToNADDRESS -7 3 / c"n1y d MAILING ADDRESS L , F rrenuu t /1rv+- oz)t -7 rAx rD (FEIN oR ssN)BEQ.U.!U.D oY 3 rrt 5-74 LICENSES RLIN ANNUALLY FROM ruLY I TO JLTNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLTNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LTNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECETVED. A HEARING BEFORE 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 ifpaid: yes-- 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 Cenification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affidavit. If not applicable, please explain: REGISTR{TION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED YN ALL SAFETY DATA SHEETS ON FILE YN ANY NEW CHEMICALS MUST Bf, PRf,-APPROVED BY THE HEALTH DEPARTMENT. APPLICANT'S SIGNATURT DATE c Lr- JN Cou"ry Pl E,Frrrr-trrt, tt O2-7t-7 RENEWAL OPPI-ICOTION X NEW APPLICATION- The Commonwealth of Massachusells D eparlme n t of I n d u s trio I Acc idents Ofji c e of I n v e s ti g atio n s Lafayette City Center 2 Avenue de Lafayene, Boston, MA 0211I-1750 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses Business/Organization Name:J-h / -(.1 fr Ce.r.- Address: '7 {Y ffnt- oP A Lt CitylStatelZip:4RiloLlr1 o?GGy Phone#: Sbf-ZC?-tltr Business Type (required): 5. ft Retail 6. E Restaurant,tsar/Ealing Establishment z. ! OIfice and,/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing Health Care Other 8. 9. l0 ll t2 *Any applicant that checks box #l mrrst also fill out the sectioD below showing lheir workers' compensation policy information. 1*lfthe corporate officers have exempted lhemselves, but the corpoBiion has olher employees, a workers' compensation policy is required and such an organization should check box #1. 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] We are a corporation and its officers have exercised their right of exemption per c. 152, S I (4), and we havc no employees. [No workers' comp. insurance required]* We are a non-profit organization, slaffed by volunteers, with no employees. [No workers' comp. insurance req.] rc vouZtA I er? Check the aan employ ppropriate box: employees (full and/am a employer with , 4 I om an employer that is providing workers' compensation insurance for my employees. Behw is the policy inform ion. Fc,lo*4 /rlufuq f ftus to Insurer's Address f' o gcv )^Lt City/State/Zip 0 U*f bh4+ t /ytl/ (fooo LoTttrlPolicy # or Self-ins. Lic. #Expiration Date Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to securc coveragc as requircd under $ 25Aof MGL c. 152 can lead to the imposition ofcriminal penalties ofa finc 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 lnvestigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and pen ties of perjury thal the infomation provided above is true snd corecl lz/a"9 e/r t LfSilureDate Phone # Olficiol use only, Do not L'rile i this area, to be eompleted bl ci4 or town olfcial. Permit/License # Phone #: City or Torvn: 5[ Selectmen's Office 6. Eother Contact Person: wrrw.mass.gov/dia Applicant Information Please Print Lesiblv Insurance Company Name: lssuing Authority (check one): tflnoaroof Heatth 2.E Building Department 3ECity/Town Cterk 4.ELicensing Board Information and Instructions Massachusetts General Laws chapter 152 rcquircs all employers to providc workers' compensation for their employees. Pursuant to this statule, an employee is defined as "...every person in the service ofanother under any contract ofhire, / express or implied, oral or wriften." An employer is 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 othcr legal entity, employing employees. However. the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house ofanother who employs persons to do maintenance, conslruction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not bccause ofsuch employrnent bc dcemed to be an employer." MGL chapter 152, $25C(6) also states that "ev€ry state or local licensing agency shrll withhold the issuance or renewal of a license or permit to operate a busincss or to construct buildings in thc commonrvealth 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 ol its political subdivisions shall enter into any contract for the performancc ofpublic work until acccptablc cvidence ofcompliance with the insurance requirements of this chapter havc hecn nrcscnted k1 thc contracting authority." Applicants Please fill oul 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 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 Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the alfidavit. Thc aflidavit should be returned 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-insurcd companies should cnter their self-insurance license number on the appropriate line. City or Town Oflicials Please be sure that the affidavit is completc and printed legibly. Thc Department has providcd a space at the bottom of the affidavit for you to fill out in the event the Office of lnvcstigations 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 givcn ycar, nced 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 may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new alMavit must be filled out each year. Where a home owner or citizen is obtaining a license or permil nol 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 affrdavit. The Office ol Investigations would like to thank you in advancc 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, MA 02111-1750 Tel. (857) 321-7406 or l-S77-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 wwwmass.gov/dia