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Home My WebLink About2025-260\e raf q3 RECEIVED Lr.ENSEnuur'r, Bl-l [-l[\-13 - )7qytr-+ .lUN I B ?[bwx oF yARMourH BoARD oF HEAI,TH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS M.{TERIALS HEALTH DEPT. LICENSE APPLICAI'ION CO}IPLETE THIS APPLICATION AND RETUR\ IT WITH THE LICENSE FEE BY JUNE 30, 2025 <-,s;I;l;il BUSINESS TEL. # 578 1.7 F-IP?-hm h/t PLEASE COMPLETE ALL QUESTIoNS NAME OT' BUSINLSS MAILIN(; ADDRESS {dhr- BUSINESS ADDRESS IN YARMOUTH C)hiy' T<cA D.Mt U,Var.nau%/U/+ozLZ3c t EMAIL ADDRESS heri @ k leicloto 'ntd-Co*t BEI}IIBED MAN AGE R/CONTACT PERSON Sjar?, (arra r TELEPHoNE t/%) >p-94> - BEQIJIBEDowN zs*erre 9kuh t, trvs ,ut.o(52?) zto-sb6t- HOME ADDRESS ]1tl u.tc,7 poa/ 4armo*fi/or/, rnA ozATS- CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS MAILIN(; ADDRESS Town of Yarmouth taxes and liegrmust be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid. yes y' no- na- 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 04 -3D1!94 LICENSES RTIN ANNUALLY FROM ]ULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY JLNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING, Compensation AffidaYit. ll not applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AN'D WORK.ERS COMP AFFIDAVIT ENCLOSED YN yN ANYNEwCHEMICALSMUSTBEPRE.APPROVEDBYTHEHEALTHDEPARTMENT. RENEWALO".,.O''O*X NEWAPPLICATION- APPLICANT'S SIGNATURE:DATE lry TEL. # TAX ID (FEIN OR SSN) REOUIRED The Commonwealth of Massochusetts Departm en t of I ndustrial Acc idents Ollice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ;JO ct nfr Address:lol c m,l *ch brir< Are l-ou an emplover? Check the appropriate box: |.Wiu a employer with or part-time).* 2. E I am a sole proprietor or partncrship 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 ofexemption per c. 152, $l(4), and ue have no employees. [No workers' comp. insurance required]+ We are a non-profit organization, staffed by volunteers, with no employees. [No workcrs' comp. insurance req.] b employees (futl and/ 3 4 U/1 Q.b13ynone#17t Business Type (required): 5. E Retail 6. ! Restauranttsar/Eating Establishment 7. EfOffice and/or Sales (incl. real estate. auto, etc.) Non-profit Entertainment Manufacluring Health Care Other 8. 9. 10. I t. 12. Ciry/State/Zip ,llvt,lrlarn t)Yf/l. *Any applicant thal checks box #l must also fill out the section below showing their workers' compensalion policy informalion. .*Ifthe corpornte officers have exempted themselves, but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. roviding workers co Pensation insurance for my employees. Below is the policf inlormotion.I am an employer that is p lnsurance Company Name rcJ Insurer'sAddress: 3lro, u)i58"{mdt1 pltd *ntbnn -Tx 17>St Policy # or Self-ins. Lic. #D7 utc cm/oq1 Expiration Date o o>G 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 ofMGL c. 152 can lead to thc imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalti€s in the lorm of a STOP WORK ORDER and a hne of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oflice of lnvestigations of the DIA for insurance coverage verification. I do herehy under lhe pains and penalties ol perjury that lhe informolion Provided above is lrue and coffecl. ture b 1 >5 Phone #<7)r)-1tr4LL Offtcial use only, Do not wrile in this ares, lo be completed b! ciq or nn'n oJJicial. Permit/Licensc # Phonc #:Contact Person: 3.8 City/Town Clerk 4. ! Lice nsing Board Citl or Town: Issuing Authority (check one): 1flBoard of Health 2.E Building Department 5! Selectmen's Office 6. Eoth€r www.mass.govldia Applicant Information Please Print Lesiblv Business/Organization Name: ciry/srate/zip: t)t lc,* Information and Instructions Massachusctts Gcncral Laws chaptcr 152 rcquircs all employers to provide workcrs' compensation for their employecs Pursuant to this slatrrle, an employee is detined 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 individ[al, pannership. association, corporation or other legal entity, or any two or more of the ioregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the ."c"iu", oit-.iee ofan individual. partnership. association or other lcgal entity, cmploying employees. However' the owner of 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 th-e grounds or building appurtenant thcrcto shall not because of such employment be decmcd to be an employer." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or rcnewal of a license or permit to opcrate 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." A<liitionalty, MGL chaprer 152,!\25C(7) srates "Neither the commonwealth noranyof its political subdivisions shall entcr into any contract for the performancc ofpublic work until acceptable evidcnce ofcompliance with the insurance requircmcnts of this chapter havc been prcscntcd to thc contracting authority " Applicants please till 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. I-imltea LlaUitity Companies (LLC) or Limitcd Liability Partnerships (LLP) with no employees other than the membcrs 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 affrdavit may be submitted to the Department of Industrial Accidents for confirmation of insurancc coverage. Also be sure to sign and date the aflidavit. The affidavit should bc rctumed to the city or town that th€ application for the permit or license is being requested, not the Departmenl 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 below. Self-insurcd companies should entcr their self-insurance license number on thc appropriatc line. City or Town Officials pleasc be surc that the affidavit is complcte and printcd legibly. The Department has provided a space at the bottom of the allidavit for you to fill out in the cvcnt thc Oflcc of lnvestigations has to contact you rcgarding the applicant. please be sure to lill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/ticense applications in any given year, nccd only submit one affidavit indicating cunent policy information (if necessary). A copy of the affidavit thal has been oflicially stamped or marked by the city or town may be provlded to the applicant as proot that a valid atlidaurt is on llle tbr luture permits or licenses. A new affidavrt must be filled oul 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 licensc or pennit to bum leaves etc.) said person is NOT required to complete this afiidavit. Thc Office of lnvestigations 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. rhe Department's address' telephone Tfl:'L:Hlrlr*ealth of Massachusetts Department of lndustrial Accidents Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston. MA02111-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7,,2019 www.mass.gov/dia ch.Na Sa{\l PLEASE COMPLETE ALL OUESTIONS NAME oF BUSTNESS K;Y4!rLCr9?6 041 rHH4- .I'OW\ OF YAR\IOI.I'IH I}OARD OF HT]ALTH 2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 <S, S eusrNpss rsr. * 52l' l 777 5)u BUSINESS ADDRESS IN YARMOUTH SbO H;Or-rll k).lar,,ro,h,r Aa od67t // MAILING ADDRESS EMAIL ADDRESS ?Kl@k;c-cafionsco. co /4 ?t;rft*lBEQUIBED MANAGE R/CONTACT PERSON TELEPHoNE # l- for-Z ZSz Z'S t t B.I.AUB.ED owNER NAME Laoacrtct-- tla "rr-^rct+54-775'5311 r{OME ADDRESS t7 "cksVia Cc,r lfc e OZb9e CORPORATION NAME (IF APPLICABLE) TEL. # CORPORATION ADDRESS MAILING ADDRESS 'l-|nrqtLt4 LICENSES RLTN ANNUALLY FROM JULY I TO JLNE 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 CLOST]RE OF YOUR ESTABLISHMENT TNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECETVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE RTQUIRED PRIOR TO REOPENINC Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check aoorooriatelr ifoaid: vcs 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 if a 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 Affidavit. If not applicable, plcase explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKIRS COMP AFFIDAVIT ENCLOSED ALI- SAFETY DATA SHEETS ON FILE yN BE PRE.APPROVED BY THE HEALTH DEPARTMENT. Nv A\I' NEIv CHEMICA RENEWAL APPLICAT LS MUST ,O* t/ APPLICANT'S SIGNATUR.E NEW APPLICATION- LICENSE FEE $I50 rAx rD (FEIN on SSNTBEUIBED oerc' 7:l7'4{ i-i The Commonwealth of Massachusetts Department of Industial Accidents Oflice of I nvestigations Lafayette City Center 2 Avenue de Lafoyette, Boston, MA 02111-1750 www,mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses - A licant Information Please Print L Business/Organization Name:V;lr,lu^" tceahrns Address: 1bO il;l^Ceo"*l CitylState/Zip:erm@,),ta DJb Phone #: k5o*775-rSlll,o4t-br 5 6 7 Retail RestauranL/Bar/Eating Establishment Office and,/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 1O.fl Manufacturing lt t2 Health Carc Other *Any applicant that checks box #l must also lill out lhe section below showing their workers' compensation policy information.*ilf the corpomte officers have exempted themselves, but the corpomtion has other employees. a workers' compensation policy is required and such an organization should check box #l . Are you an employer? Che t.d t u, a employer with or part-time).* 2. E I am a sole proprictor or partnership and have no employees working for me in any capacity. INo workers' comp. insurance required] 3. E We are a corporatron and its ofllccrs havc exercised their right of exemption per c. 152. S I (4), and we havc no employees. [No workers' comp. insurance required]* 4. ! We are a non-profit organization, staffed by volunteers, with no employecs. [No workers' comp. insurance req.] ck the appr q opriate box: employees (full and/ I an an empkryer that is providing workers'compensalion insurance lor my em'pbyees. Below is lhe polit'y information. Insurance Company Name u v( 7r'tLI lnsurer's Address p 0 iloy )Zt City/Srate/Zip O^safonna , An 5€91o9 lrc'7at r Expiration r,n", rfqf ?oaOPolicv # or Self-ins. Lic. # Attach a copy of the workers' compensation policy declaration pag€ (showing the policy number and expiration date). Failure to secure coveragc as rcquired under $ 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a 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 tine of up to $250.00 a day againsl the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pdns tnd penalties of periury thst the information provided above is true arrd coruect. Sicnature Date Phone # Olftciat use only, Do not write in this area, to be completed by city or town ollicial. Permit/License # Phone #:Contact Person: 3.8 City/Town Clerk 4. ! Licensing Board Citv or Tor n: lssuing Authoritr' (check one): lflBoard of Health 2,E Building Department 5[ Selectmen's Oflic€ 6. Eother www.mass.gov/dia Business T1-pe (rrquircd) : Information and lnstructions Massachusetts General Laws chapter 152 requircs all employers to provide workers' compensalion for their employees Pursuant to this sta te, an errrployee is defined as "...every person in the service ofanother under any contract ofhire, 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 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 entitv, emplolng employees. However, the owner ofa dwelling house having nol more than three apartments and who resides therein, or the occupant of the dwelling house ofanother who employs persons to do maintenance. construction or repair work on such dwelling house or on thc grounds or building appurtenant thcreto shall not bccause of such employment bc deemed to be an employer." MGL chapter 152, $25C(6) also states that "ev€ry state or local licensing agency shall withhold the issuance or renewal of a Iicensc or pcrmit 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, S25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enlcr into any contract for the pcrformancc ofpublic work until acccptable evidence ofcompliancc with the insurance ' requirements of this chapter havc been prescntcd to the contracting authority." ,4pplicants 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 Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. lfan 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 covcrage. Also be sure to sign and date the affidavit. The aflidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of lndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy. please call the Department at the number listed bclow. Sclf-insured companies should enter their self-insurance license number on thc appropriate line. City or Town Officials Plcasc bc surc that the affidavit is completc and printed legibly. The Departmenl has provided a space at the bottom of the allidavit for you to fill out in the event thc Office of lnvestigations 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 current policy information (ifnecessary). A copy ofthe affidavit that has bcen officially stamped or marked bythe city or town may be provided to the applicant as proof thal a valid at-fidavit is on file for furure oermits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or pemrit to bum leal'es etc.) said pcrson is NOT required to complete this affidavit. The OIfice of Investigations would likc 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, lelephone 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 Rcvised 7/2019 WWW.maSS.gOV/dia ot nu2025 DO€S NOT AEFIRMATIVELY OR EOATII/EIY AMEND, E(IEIO OB ALTER IHE COVERAOE AFFORI)ED BY IHE POUCIES ELo!IY. IHIS CERTIFICATE OF INSURANG OOES NO] CONSTITUTE A CONTRACT B€IV/EEN THE ISSUINO INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODI'CER, AIIO ITC CERTIFICATE HOL.OER. IHIS CERTIFICATETHIS CEEIIfICATE IS ISSUEO AS A MATTER OF TION ONTY AND CONFERS NO RIGHTS UPOII THE CERTIFICATE SUSnOOATtOtt tS WA|VEO, srajccr to A|. te'Irls sd cs|dillons ol th. pollcy, cstdn pollcl6 lrny rECIro Il lrxb.slflEr|t A stil€n nt fi tlir c..tificrtc does r|ot corn.r rlghts to ttl. c.rlifirde no5.t ln llai d $ch .n&r=!llctl(s). L INSURED pror/slons o. h€ edorsr(l.IMPORTANT holder ls .n ADOITIONAL INSURED. th€ CLIENT CONTACI CENTER rATc, io)r 507-4464wl88&333-4949 !3]!!E!I99!I49IqE!!I!8@FE!l! !.ce! li'UiEN *FEDERAT€O RESERVE INSURANCE COMPANY FEDERATEO MUTUAL INSURANCE COMPAI{/ HOME OFFICE: P.O. BOX 328 CAA/ATONNA, MN 55060 16024 KIICHEN CREATIONS, INC. 5M HIGGINS CRCTA'ETI RD WEST YARMOUIH, MA 02673.2570 ()ta COVERAOES CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE NUMBER 7 REVISION NUMAER:1 CANCETLATIONCfRTIFICAIE HOLTXR DAVE MANN NG CON sTR!CT|ON lfic 11 PO BOX 217 CUMMAQUID, MA MM7.0217 SHOUI.O ANY OF THE AAOVE O€SCRIBED POUCIES BE CAIIC€LT.@ EEFORE THE EXPIRATION OATE THEREOF, NOTICE WILL BE OELTI/ERID ItI ACCOROANCE IYITH THE POUCY PROVISIONS, D"l"!" (2"^ TIIIS IS TO CERT FY TITAT THE POLICIES Of INSURAN CE LTSTED BELow tssuEo lo tHE tNsuRED NAMEo aBovE FoR IHE PoLlcY PER oD lNolcArEo r{oTwtTrETANDlNG Axy FEQUTREMEIIT, TEFU OR @ DtTtOi OF ArY @liTiACT OR OTHER DocUUAlT WlTrl RESPECT TO WtrrCH IH|S CERTTFTCATE tlAY AE ISSUED OR MAY PERTAIN TIE INSURAXCE AFFORDEO AY I8E POUCIES OESCRIAEO HEREIII IS SUBJECT IO Al.I THE TERMS EXCLII;IOTIS AI{O @NO]TIOIIS Of 6UCH POI.ICIES, LIMiTS SII@/N MAY HAIE BEEN REDI.EED BY PAID CIAIMS cullt{rE Elocc"r fl N -.., f-tlq --l.oc 6r26259 aal14/2@s o\t1tt2a26 $1,m0,m0 DA',IACE TO iEI{TtO PREri'SE6 s100.m0 EXCLUDEf Pr!!g!!r i ag]]lrgry s1,m0,000 s2 000 m0 s2,000 000 6126258 08t14t2925 aat14t2a26 lE..diir.n! EODILY IIJUIY IF.T FE,N 31,m0 0c0 x x N N 6126260 4411412025 o8t14t2426 s1,m0,m0 s1,000 000 -f,o-ffiscoMftar'or f *,oL n 1807235 au14t2a26 X i500.@0 s500,000 s500,000 I o€scRrPfox oa o?EialroN€ r locAnoNs /vEHlcLES lraoiol0l, Addirll Rrn. t 6d.dur.. r, !. .ft6.d rl no. t.o acoRo 251?016/03) @ ls.2l}15 ACORD CORPOnATION- Al rirns Es€rved. TIE AcoRD na,nc and logo rc Egitt€rcd msts oa AcoRD x x rurdorrrE r.llErutY I r l*'^-" In lowreoeurce orLvl l!!ffiu=o N I * l,*ro^,,*c.,.' I ll$HH,tg I-nl BODlLv iJUFY lP.' &. d.ir) aat14t2u25