HomeMy WebLinkAbout2025-260h Notr{0
r-rceNse 6 Hl"t-Z;-l
FEE: S150.00
TOWN OF YARMOUTH BOARD OF HEALTH
2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS
LICENSE APPLICATION
PLEASE COMPLETE TTIIS APPLICATION AITD RETURN TT WITH THE LICENSE FEE BY
JI'NE 30, 2025
PLEASE coMpLErE ALL euEsrroNs e, Sciiil:Il
NAME oF susrNess fkl flarrinerr Q,pruxt BUSrNEssrEL. # Oft-171"\W1
BTISI..lESS ADDRESS IN YARMOUTH 64b ulL Pg u).a tl ,dA t1A -02641
ILNG ADDRISS -Sarnno Ag A-leow-
REGElI7tr@
s 2025
DEPT
a
E\IAIL ADDRESS ( N r, e'tr
i ILANAGEII"'CONTACT PERSON b ni9 ?^tQL
. ,,,;ts * 60$- ++l-tAg)
C,^,,* P^fal TEL.#).,!NERNAME
is) - 3 4tr9-Ae *Un+e--
oob-7T1.@
CORPOR\TION NAME (IF APPLICABLE)rla". 6a qt"i &LrTjr.* 6W..)TL-+ffi
CORPORATION ADDRESS
MAILING ADDRESS
-9Atr4r-ks Ato"e
1\
4+- h 2 6az-55
,. I1]E}, SES !TU:" AN.\IUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN
TJ tt, (.,O1\,IPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JTINE 30. FAILURE TO DO SO WILL
Rl ST,I.T I.- CI,oSURE OF YOI,IR ESTABLISHMENT I,NTIL THE REQI.IIRED APPLICATIONS(S) AND- I {r' \R Ll RECEMD. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
t,
. ), r,i.nroul.h taxcs a\d liens must be paid prior to renewal or issuance of your permits. Please check
,";,rqlr ifpaid: ,..11 oo- ol;-
,,; . i:]prcr 152, Sec. 25C, subsection 6, the Tom of Yarmouth is required to hold issuance or renewal ofany
.rt . ,,, ..i, n;t tc operate a business ifa person or company does not have a Certiltcation ofWorkers Compensation
. : . : ,:,I renewal or issuance ofyour perrnits, you must complete the enclos€d Workers Compensetion
:r, 1 ,rpplicable, please explain:
RLGISTR-\I ION FOR.VI SIGNED AND COMPLETED
CHECK Al'*D WORKERS COMP AIFIDAVTT ENCLOSED
ALL S {FETY D,{TA SIIEETS ON FILE
ANY \EW CHE]ITICALS MUST BE PR.E.APPROVED BY THE IIEALTH DEPARTMENT.
RL,NEWAL APPLICATION / NEW APPLICATION
/
Y
^,/Y
N
N
0t 7b
Nbla,{PPLICANT'S SIGNATI,.IRE
DATE IO
. orn
rAxiD(FETNoRSSNEE@
Print FormThe Commonneolth of Massachusetls
Depanment of lndustial Accidents
Atfi ce of I nvestig oti on s
I Congress Ste4 Suite 100
Bostott, MA 021l4-2017
w*w.moss.gov/dia
\i rrrkers' Compensation lnsurance AIIidavit: General Busincsses
l
e-><t
:! :. \, hj?2 o,r*e. 2-g
ar'\h ,r)'1",nA'd)Ct\ phone#: SOVAq-+gsa
\rr r r irri ,rmplolr'r'.' Chrck the epproprirte bor:
o employees (full andi
(rr Prrl-lrluel.t
I .rnr u :ol.' prcrpriclor or prrnnership and haveno
rnrplcryrr. rrorkrng for mc in any capacity.
l\r:, r' orlcrr'cornp, insurance requircil
: , ,: ir. ; l ;1,rpe1ugiol rnd its oflir;ers have exercised
, ., i- .:ilhr,)l crlxrlplion perc. 1.52. $l(4).andwc hate
, f.ir'1,-!5 l:r.-o norkcn'comp. insurance requiredt'
.r , i rr.,rr'prL)tjt organization. saffed by volunrc*rs.
ir r . es. [No workers' comp. insurance req.]
Business Type (required)
5. D Rehil
6.
8.
9.
r0
lt
t2
! Restaurant/BariEadng Establishment
! Offrce and/or Sales (incl. rcal cstalc, aulo. €tc.)
Non-prolit
E nterta inment
Monufacturing
Health Care
ffcr,l"t *loteL tlrt e!.
tr
D
tr
U
StateiZip
I nnr:r cnployer rvi$r _
rLl
I
r ., rrrr:.r ltho lill oE thc scclion hch)rr \h(nving thekuorkcN'to,n enjalion lolicy hfoflturli(nr.
l, :.'cl1r;,!,.(i lhctnssh-rs. trur rhc corJxr.aiioD h.Lr otlwtemploy-ttx. a *trkc.3' con{Ersalion policy it rcquir.d tnd ru{h on
t,.t
otiding rl.otken'uratce lor my employets Below is tht politl inlormation.
\ol fi9^TA/x
.:r \,: .. Or,a Paf k Poloco 5@ Y.e,h sle*-l-;.L
,N5 - lb2oL
A.
+tt^'
l\rlir'r ! rrr {cli'rn:. [.rc. 1, Expiration Date
, t, ,t, ,,, ij.r., B 1,lct
\gsih r ropr (,[ rhc rl(,rkers' compenfatlo[ polic, dechrrtim prge (shoning the pollcy numbcr rnd expirrtlo[ date).
:r,lrrrr r. rc.rre (1r\erxll{ asrcquircd under Section l5A ol'N'IGL c. t52 can lead l(} the imposition of criminal penaltien of a
r lL ,r:1 r(. \, i.5(iir.urrtnd (\r o'lc-year imprisonrncnt. as wcll as ciril penalties in lhe form of a STOP WORX ORDER and a linc
r (t:' r,,!:ii)ilt)iltl.r] xlai,Lrr thc r iolator. Be advis".d tlut a copy of this stal!'meol may be t'or*'arded to the Oflicc of
a:li, l)1,\ l'+r insurance covcmge veriltcation
s and penalties of perjurl that lht ififon.trton pruided above is lrue and .'orre.'t
0
l1
{;it\ or 'l orr.r
Dt1 not nrit. in lhis areq to be complued by cig'or tol,w olficial
I' r'i'r::.\rtli!{,-ilv ((irtle0[():
l. *(,.,:C,;l ttc lth 2. Buildltrg D3prrtmcnt 3. Citln'owE Clerk
6.oth.r
Permit/Licen3e #-
4. Licensing Board 5, Selectm€n's Oflice
( irnl!rl Pcrton:
rvr$ nurs.gosrdit
t,,triie;:rrt lrrlirrnration Please Print Legiblv
Y1,rllr\neY R
comp!fitstitt,t
Phone #i
10/6125, 10:04 AM
INCTICE TO EMPLOYEES ii' i
T I..l E COMh4ONI'VEALTH OF MASSACHUSETTS
DEPARTME}.{T OF INDUSTRIAL ACCIDENTS
[F VOU ARE INJU RED ON THE JOB:
!.-nei.,.tel\ notify your employer that you havo bcen injur€d.
, -- ,.r',rers Compensatron Conlacl Phons Number
-rci.i
"rcvider that you have been iniured at wort and give tho information below:
Address
One Park Place, 3OO South Stat€ St, 7th Floor,
Syracuse. NY, 13202
4cctog{$
Phone Number
(800) 327-3636, , t, lr,sir.aace Company
Address
573 ROUTE 28 WEST YARMOUTH MA 02673.4948
'-.-. ?r,prcyer taiis to report th€ iniury lo the insurct, lho employee may file an Employee's Cla:r[ (Fornf
i._,. .,. i,1.!.nta..ton.egarding your dghts ancl oligibllity for bonelits pu6uant thc Wo.kers' Ccmpensation
L? ,1. ot obtarned by contacling the Dopartmsnl ot lndustrial Accidsnls al 617.727.4900 or visiting
;'. : .:"'.:0,ttQ!9
IF MEDICA L TREATMENT IS NEEDED:
it. ^.t:1 t!,rrre(t.rlzry select lheir own medical plovidor. Medical lreatmsnt cosls thal ato teasonabls. necossaly.
i I t '.t .,'./- ti,.e florv r nlJry will be paid by the above-namod insurea.
' t / itlonnal|on is provided below, lho above-named insurer has a. .r'lt, afiangemenl and lhe insurar has arrangsd tor your initial
t. . tt!. Lt.'"lF:'.frtt.
'ltf
""t.1" ':l.: .l
R... ltt
i rllili:
,t;- | ,f tt ,t,) i|.lt ,u!! at llrltt 0ut AtuPolll(,vylttRt tMp(oyttscaN
{,( 1 " , ,r ,t. , ,} t t ,t-t1 i!;r SlLlr()t{!21 22 ju aNtr/!B1r} lMpt()yttasMAy(()lt!lit.. t.1t ',t,t l,rrr.,rrrlI tlrr Al-t,t)t<l,All1,I VYll.l ANI l\Pf it(.Aljtt l.itAtt O|lttU!tlAttl j,a ,, 1 . rr I rjrt', 'lrrJr,.i?Alr{rN ,,AlUr,t ()l( l,ltt)Vll)l lAr:,t tNr()i{M/\ti()NAUOUl
_1.,; )t,1.,-ti -t):t.t/t tN'.tt tt(/N ttio(,t1,5 tu llllllitMpt()ytt5 lllis Notitt. MUSI 6!t)l,t,rtt:. t,l) 'r l, Anl) klOlSllilBulll) YlHth ltltNl All! lllAt{cl5 lo I}ll
,I
t
.,
Fo.t$WC 88 20 0'l G Prlrtad in U.S.A
C,
C,
htips://m z it.g oog lo. co m/mail/u/O/#search/workors+comp/FMfcgzobfLQCWFJkJ LKTRSLhwNdDImxO?proJoclor= 1 &mo3aagEPartld=0. 1 111
workers comp 2025 (p1).jpg