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Home My WebLink About2025-26r(qurb'l -BA LIN -r3 -/t=r PLE AS 202sl2026 HAND E COMPLETE THIS LICENSE FEE: $ 150.00 TOWN OF YARMOUTH BOARD OF HEALTH LING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION APPLICATION AND RETURN IT WITH THE LICENSE FEE BY .LlN E 30, 2025 PLEASE COMPLETE ALL QUESTIONS NAME OF BUSINESS Kinqsbury Townhouses BUSINESS TEL. #508-398-2293 BUSINESS ADDRESS rN yARMOUTH 193 Camp Street, West Yarmouth, MA 02673 MAILING eppngss 20 North Main Street, South Yarmouth. MA 02664 erSvr tttrt l EMAIL ADDRESS cdavenport@thedavenportcompanies.com REOUIRED MANAGER/CONTACT pERSON Christian Davenport TELEpHoNE 3 508-31 4-3291 REQUTRED owNER 114yg Davenport Realty Trust 1p;.6 508-398-2293 CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TEL. d TAx ID (FEIN oR SSN) BEQUIRED LICENSES RUN ANNUALLY FROM JULY I TO JUNE ]0. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLTCATION(S ) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQI.]IRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENINC Town of Yarmouth ta.res and liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes x no a- Under Chapter 152. Sec. 25C. subseclion 6. the Town of Yarmoulh is required to hold issuance or renewal of any license or permit Io operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As part ofrenewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Aflidavit. Ifnot applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFTDAVIT ENCLOSEI) YN ALL SAFETY DATA SHEETS ON FILE X N ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION X NEW APPLICATION- APPLICANT'S SIGNATURE )dDATE0 MAILING ADDRESS HOME ADDRESS 20 North Main Street, S. Yarmouth, MA 02664 04-220867'l X The Commonwealth of Mossachusetts D epartme nl of I nd uslrial A ccidenls Ofice of Investigations Lafoyette City Center 2 Avenue de Lafayette, Boston, MA 02lll-1750 www.mass.gov/dia Workers' Compensation lnsurance Affidavit: General Businesses inr Business/Organ ization Name: Davenport Realty Trust Address: 20 North Main Street Are you an employer? Check the appropriate box: t.E t am a employer with or part-time).* employees (l'ull and/ 2.E J. L I 4.8 I am a sole proprietor or partnership and have no employees working lor me in any capacity. [No workers' comp. insurance required] we are a corporation and its officers have exercised their right ofexemption per c. 152. $1(4). and we have no employees. fNo workers' comp. insurance required]*+ We are a non-profit organization. staffed by volunteers. with no employees. [No workers' comp. insurance req.] Ciry/Srare/Zip . South Yarmouth, lVlA 02664 Phone #: 508 398 2293 5. 6. 7. 8. 9. l0 ll Business Type (required) l2.E Retail Restaurant/Bar/Eating Establishment O{fice and/or Sales (incl. real estate, auto. etc.) Non-profit Enterlainment Manufacturing Health Care 66r", Rentals *Any applicant that checks box #l must also fill out the section below showing their workers' compensation policy information. **lfthe corporate olficers have exempted thernselves. but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. lnsurance Company Name Zurich American lnsurance Comany lnsurer's Address: See attached City/State/Zip Policy # or Self-ins. 1-;g.9WC8196132 Expiration Date 3t112026 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 lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisonment. as well as civil penalties in the form ofa STOP WORK ORDER and a tine ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of I nvestigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties oJ'periury that the inlbrmation provkled above is true and correct. Si 7r,/T)w\rat,o/,,/,"2t Phone #:508-760-9270 Oflicial use only. Do not write in this urea, to be completed fu ciE or town oflicial Permit/License # Phone #: 3.E Ciry/Towtr Clerk 4. E Licensing Board City or Town: Issuing Authority (check one): l.flBoard of Health 2.! Building Department 5[ Selectmen's Office 6. Eother Contact Person: w'nrv.mass.gov/dia Aoplicant Information Please Print Legiblv I um an employer that is providing workers' compensalion insurance for my employees. Below is the policf information. ..ACORD DAVEREA-OI GERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE lS ISSUED AS A MATTER OF INFORMATION ONLY AllD CONFERS NO RIGHTS UPOI'I THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRITIATIVELY OR I'IEGAnVELY AMEND, EXTEI{O OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 2t'10t2025 IMPORTAI.IT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSUREO provisions or be endorsed. lI SUBROGATION lS WAIVED, subject to the terms and conditions ol the policy, certain policies may require an endorsement. A statement on this certilicate do€s not conte. righls to the certificate holder in lieu ot such endo.sement(s). E 6'10 458-3659 484 955-9627 INSU RER(SI A F FORDING COVERAGE '16535tNsuRER A:zurich American lnsurance comDanv Valley Forge Captive Advisors E. K. lrlcconkev & Co.. lnc. 630 Freedom dusiness Center Orive King Of Prussia, PA 19,106 INSURER C INSURER E: INSUREO ERAGES BER NN MBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOO INDICATED NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWTH RESPECTlO\AfiICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LII!,'IITS SHOWN I\4AY HAVE BEEN REDUCED BY PAID CLAIMS B EACH OCCURRENCE 1,000,000x TEO 1,000,000s 1,000 N 1,000,000 2,000,000 2,000,000x 1O8196255 31112025 COMMERCIAL GENERAL LIABILITY x G .IE'T CLAIMS.MAOE OCCUR LOC L AGGREGATE PoLrcY E AINEDSINGLE LLMIT 1,000,000$ x MAGE 311t2025 311t2026BAP8196256 A AUTOMOBILE UABILIW OllNEDAUIOSONLY HIREDAUTOS ONLY SCHEOULEOAUTOS NONOI/VNEDAIITOS ONLY EACII OCCURRENCE TE 5 OCCUR CLAIMS.MADE UMBRELLA UAB EXCESS UAB DED RETENIION 3 x ENTH 1,000,000 1,000,000E.L DISEASE,EA E - POLICY LIMITEL 1.000,000 8196132 31.12025 311t2026 A WORKERS COMPENSATION AND EMPLOYERS' UAAUIY ANY PROPRIETORFARTNER/EXECUTIVEOFFICER/MEMBER EXCLI]DEO? N OF OPERATIONS below CA Tolrrn of Yarmouth Route 28 South Yarmouth, ttlA 0266'l SHOULD ANY OF THE ABOVE OESCRIBED POLICIES AE CANCELLEO BEFORE THE EXPIRATIOX DATE THEREOF, NOTICE WILL BE DELTVERED IN ACCORDANCE wlTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATTVE /r,q1- ERTIFICATE O 1988-2015 ACORO CORPORATION. All rights reserved The ACORD name and logo are registered marks of AcORD ACORD 25 (2016/03) Davenport Realty Trust 20 North Main Street South Yarmouth. MA 02664 PRODI]'TS, COUP/OP AGG 3t112026 OTH tr oEscRtpTtoN oF opERATtoNs r LocattoNs / vEHtcLEs (AcoRD 1 0l , addition.l Remrr. schedule. By b. rttech.d ir moe 3p.ce aa Bqui€d) Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this statute, an emplolee is defined as "...every person in the service ofanother under any contract ofl 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 ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer. or the receiver or trustee of an individual. partnership. association or other 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. consruction or repair work on such dwelling house or on the grounds or building appunenant thereto shall nol because ofsuch employment be deemed to be an employer." MGL chapter I 52. $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for atry applicant who bas trot produced acceptable evidence ofcompliance with the insurance coverage required." Additionalll,. MGL chapter 152. $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract lor the perlbrmance ofpublic work until acceptable evidence ofcompliance with the insurance requirements ofthis chapter have been presented to the conlracting 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 of insurance. 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 afiidavit may be submitted to the Department of tndustrial Accidents fbr contirmation of insurance coverage. Also be sure to sigtr aDd date the affidavit. The affrdavit should be retumed to the city or town that the application lor 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'-insured companies should enter their self-insurance license number on the appropriate line. City or Town OIIicials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe afiidavit for you to fill out in the evenl the Olfice of lnvestigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. [n addition. an applicant that must submit multiple permit/license applications in any given year. need on-ly submit one affidavit indicating cunent policy information (ifnecessary). A copy ofthe atlidavit that has been o{Iicially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses- A new afTidavil 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 permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of lnvestigations 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 t'ax number: The Commonwealth of Massachusetts Department of Industrial Accidents Olfice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston. MA0211l-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/201e WWW.maSS'gOV/dia