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Home My WebLink About2025-26oY- \t"'{oo LT.ENSEFEE$r5o Rilt+-2< -t8tu5 TO\Yr- OF YARNTOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOIIs.M.{TERI A LS LICENSf,APPLICATToN rtEU'r-i:'E:!' COMPLETE THIS APPLICATION AND RETURN IT WITH TH4 I"ICENSE FEE BY JUNE 30.2025 )t) HEALPLEASE COMPLETE ALL ()t rEsTIo\s NAME OF BUSINESS rli BUSINESS ADDRESS tN YARMOUTH BUSINESS TEL, 4 63 MAILING ADDRESS I]MAtL ADDRESS BEIIIJ.IBED MANAGER/CONTACT PERSON TELEPHoNE# 9JP' +n ?z-o4 R1'OL;IR1'D OWNER NAME Geo.o, $\ld rctt l-ttl41181ZS r'n M Cc i--.>urie ttr\t vrlllir HOME ADDRESS CORPORATION NAME ( IF APPLICABLE)rs-.* fr1uz14ul CORPORATION ADDRESS MAILING ADDRESS rAx rD (FEIN on SSNTBEQUIBED D+- Zh<1t+B LICENSES RUN ANNUALLY FROM JULY I TO JLINE 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 UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. 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-L 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, plcase explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ,/ N ALL SAFETY DATA SHEETS ONFILE { N ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. L APPLICANT'S SIGNATURE W APPLICATION DATE k(rtl'< 44ttr* RENEWAL O"'''O''O* / The Conmonwealth of Massochusetts Departm en t of I n d u strial A cc i de nts Offi c e of I n ve s ti g ati o n s Lafayette City Center 2 Avenue de Lafayene, Boston, MA 021I l-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses .- ,?a Business/Organization Name Address: 253 Nlittr^ra- CL Po lZo* 322- CitylStare/Zip Phone #: Are y.ou an employer? Check th€ appropriate box: LV t u* a enrployer "in /3 employecs { full and or part-tinre).* 2 3 .l I am a sole proprietor or parmership and have no cmployees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their righl ofexemption per c. I52,$l(4),andwehavc no employees. [No workers' comp. insurance required]** We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] *Any applicantthat checks box #l musl also fill ou1 the section below showing their workers' compensation policy infotmation.**lf the corporate officers have exempted lhemselves, but the corporation has other employees. a workers' compensation policy is required and such an organization should chock box #1. ({ 12.! Other Insurance Company Name |r,buh, Nulwxl l4fuv'a,t ce 1".0v'D. Insurer'sAddress: ''< Pr;f,nt* fi Ciry/Srate/Zip Policy # 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 secr.ue covcrage as required undcr $ 25A of MGL c. 152 can lead to the irnposition of criurilal pcualties ofa t-ure up to $1.500.00 and/or one-year imprisorunent, 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 of this statement may be forwarded to the OfIice of Investigations of the DIA for insurance coveragc verification. er the pI do hereby tulc P g1 alties ofperjury thst the information provided aboye is true and correct. Date Official use onll'. Do not write in this area, to be completed by city or tot'n officiol Permit/License # Contact Person:Phone #; 3f-'l City/Town Clerk 4. ELicensing Board lssuing Authority (check one): lflBoard of Health 2.! Building Department5[ Selectmen's Office 6. EOther www.mass.gov/dia Applicant Information Please Print Legibly blt,fd\ 0 Business Type (required): 5. ! Retail 6. ! RestauranuBar/Eating Establishment Z. ! Office and,/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacruring I l.! Health Care I am an employer that is providing workers' compensolion insurance for ny empktyees. Below is lhe policS' informuion. Citv or Town: Information and Instructions Massachusctts General Laws cbapter 152 rcquires all employers Io providc workers' compensation for their employees Pursuant to this statute, at ernployee 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 represenlatives ofa deceased employer, or the receivcr or trustee of an individual, partnership, associalion or othcr legal entity, employing cmployees. However, thc 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, construclion or repair work on such dwelling house or on thc grounds or building appurtenant thcreto shall not because of such employment be dcemcd to be an employcr." MGL chapter 152. $25C(6) also slates that "€very state or local licensing agency shall withhold the issuance or renewal of a licensc or permit to operatc a busincss 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 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pcrlbrmance ol'public work until acccptable evidcnce ofcompliance with the insurance rcquircmcnts of this chapter have hccn prcscntcd to thc contractinq authoriry'.'' Applicrnts Please till out the workers' compensation affidavit completely, by checking lhe 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 othcr than the membcrs or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affrdavit may be submitted lo the Department of lndustrial Accidents for confirmation of insurancc coverage. Also be sure to sign and date the aflidavit. The a{fidavit should be retumed 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. Sclf-insured companics should enter their self-insurance licensc number on the appropriate line. City or Town Officials Pleasc bc surc thal lhc affidavit is complctc and printed lcgibly. The Departmcnt has providcd a space at the bottom of the affidal'it for you to fill out in the evcnt the O(fice of Investigations has to contact you regarding thc applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. ln addition. an applicant that must submit multiple permit/liccnse applications in any given year. nced only submit onc affidavit indicating current policy information (if necessary). A copy of the affidavit that has bccn officially stamped or marked by the city or town msl bc provided to the applic:urt as proc,fthlt a ','alid :ffirja., it is on file for frrturc permits or !iccnscs. A nev, affidarit 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 pcrmit to bum leaves etc.) said person is NOT required to completc this affidavit. 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. MA021ll-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-'7749 Form Revised 7 2019 www.mass.gov/dia The Office of Investigations would likc to thank you in advance for your cooperation and should yori have any questions. please do not hesitate to give us a call. TYORGRS COMPENSATION A,IID EIIPLOYERS UABIUTY INSURANCE POLICY INFORMANON PAGE INSURANCE 175 gertelsy StsE t Bonoq XA 02'l'16 AR lssued by Lll INSITRAIICE CORPORAI ION Policy Number I{C5-31S-481609-035RENEIIATOF: IiCS-31S-4816O9-O24 Account Number 1-t181 609 1. lnsured ard Mdling Address MILLWAY MARTNA INC 21243 lssuing Office 016C lssue Date LL-21-24 Sub Account 0000 RISK ID 303502 253 MILLIIhY RD PO BOX 322 BARNSTABLE. }IA 02630 Status 03 - CORPORATION Other workplaces not sho,vn So\re: SEE ITEM 4. PREMIUM - EXIENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 01-06-2025 to 01-06-2026 '1201 AM. stardad tire at the lnsured's mdling address. 3. CoverageA Workers Canpensdion lnsurerce: Pat One of the policy ?plies to the Workers Cornpensation Law of the states lisled here: llA B. Employers Liability lnsurace: P{t Two of th6 policy edbs to work in edr state listed in ltern 3.A The limits of our liability under P t Two ae: Bodity lniury by Accident $ 1 , 000 , 000 eeh eident Bodily lnjury by Dsease $ 1,000,000 policy limit Bodily lnjury by Dsece $ 1.000,000 eeh ernployee C. Olher Stabs lnsur lc6: Prt Thr* of the policy +plies to the stdes, if aly, lbted here: SEE END lIC 20 03 068 Classifications Code Number Premium Bas is Totd Estirnated Annud Fhmu neration Rate per $100 of Rernu neration Estirnated Annud Prernium S€€ Extension of lnformation Page Minimum Premium Premium will be billed ftoducer -20&19{ HT'B INTERNATIONAI NEW ENGITND LLC 600 LONGWAIER DR NORIiELL r,IA 02061-9146 v1/c 00 m 01 AEd.BtlotTn Totd Estimated Annud Premium $ 11. {49$ ANNUAL 239 (uA) Page 1 of 1 w Libefi Mutual. D. This policy includes lhee endorsenents md schedules: SEE EXIENSION OF INFORMATION PAGE 4. Premium: The Eemium for this policy will be determined by our lvlauds of Rrles, Clssifications, Rates gld Rating Plans. All information requircd below is subiect to treriitcation md ch ge by aldit.