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LICENSE FEE S I50
TOWN OF YAR}IOUTH BOARD OF HEALTH
202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATER]ALS
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BY JUNE 30. 2025 JUt't
PLEASE CO ALL OTIESTIONS fiEqt
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NAME OF Bt.rSINhSS y'l'A(.., cp G r l,t,svt ,l\--T-
BUSINESS ADDRESS IN YARMOUTH
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BUSINESS TEL. #
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MAILING ADDRESS
EMAIL ADDRESS ,-\
BEqLIBED MANAGER/CONTACT PERSON {?x,L t Jzr r.Jlo
TELEPHONE #s68-q- t("t4
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R[-OUIRT'D OWNER NAME (l'cL t flahn-\ \Jrrntd{p- rsr.+,l-
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CORPORATION NAME (IF APPLICABLE)
CORPORATION ADDRESS
HOME ADDRESS
L/-C_TEL. #
4
TO REOPENING
Town of Yarmouth taxes and l.iens must be paid prior to renewal or issuance of your permits. Please check
appropriately it paid: yes11 no- n,a-
Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any
license or permit to operate a business ifa person or company does not have a Certification ofWorkers Compensation
insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers
Compcnsation Affidavit. Ifnot applicable, please cxplain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ON FILE
N
"/:L
Y
N
ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT.
RENFWAL orrrrc orro" ,,/ NEw AppLrcATIoN-
APPLICANT'S SICNATURE DATE I\
I
MAILING ADDRESS-
TAX ID (FEIN ON SSN)BEQUIBED
LICENSES RI.IN ANNUALLY FROM JULY I TO JL]I'IE 30. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQURED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESULT IN CLOSURE OF YOUR ESTABLISHMENT LTNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
r
I1MPLIIYERlf Worters' Compnsation and Erployers Uability
lnsurance Policy
-_-
EM PLOYERS ASSURANCE CO
A Stock Company
Additional Locations:
2. The Policy Period is from06/01l?O25 to 06101l2026 12:01 a.m. Standard Time at the lnsured's mailing address.
3. A. Workers Compensation lnsurance: Part ONE of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability lnsurance: Part TWO of the policy applies to work in each state listed in ltem 34
The limits of our liability under Part TWO are:
Bodaly lnjury by Accident $ 1,OOO,OO0 each accident
Bodily lnjury by Disease $ 1 ,000,OO0 policy limit
Bodily lnjury by Disease $ 1,OOO,000 each employee
C. Other States lnsurance: Part IHREE of the policy applies to the states, if any, listed here;
All states except ND, OH, WA, WY and states listed in item 3.A.
D. This policy includes these endorsements and schedules: See attached schedule.
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans
All information required below is subject to verification and change by audit.
SEE D(TENSION OF INFORMATION PAGE
Minimum Premium 212 &pense Constant
Prernium Discount
338$$
$
$4,405Assessments and Taxes $
! This is a Three Year Fixed Rate Policy
Premium Adjustment Period: I Annual;
Total Estimated AnnualPremium
E Semiannual; D Quarterly; E Montnty
Countersigned this Day of
lssuedDate: O4l2?l2O?5
lssuino Office EI\,IPLOYERS ASSURANCE CO." P.O. BOX s39003
HENDERSON, NV 89053.9003
lssued Date 0412212025wc99o63o (5/98 Ed.)
INSURED COPY
Page 1 of 4
Policy Number Policv PeriodFrom - To
EtG 45s63s6 0s o6/o't/2025 06101t20?6
ln*red .. itlted her€in
Transaction
RENEWAL DECLARATIONS
NCCI Carrier # 36870 WCIRB CARRIE#
1. Named lnsured and Address Agent
MID CAPE COLTISION
56 OLD TOWN HOUSE RD
SOUTH YARMOUTH MA 02664
ADP . FLORHAM PARK - SERVICE
FLORHAM PARK . SERVICE
1 ADP BLVD., M/S 625
ROSELAND, 'IJ 07068
0033001
Telephone: 8OO5247O24
Customer #Carrier #
36870
FEIN #
80066',I 184
Risk lD #
0001 77 155
Entity of lnsured
INDIVIDUAL
Authorized Representative
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PRJOR POLICY NUMBER EIG455635604