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Home My WebLink About2025-26fi-14 I-ICENSE FEE $ I50 TOWN OT'YARMOUTH BOARD OF HEALTH 202512026 HANDLINC AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICf,NSE APPLICATION coMPLETE rHrs APPLICATIOI{aNDIETURN Ir \l'IrHf,EtHfrrTr ."" Br\ilrv-:=-ln.fS ,o , PLEASE COMPLf,TE ALL OUESTIONS NAME oF BUSrNass Y\5\S {).:t5-.>qLS susNess HBkrHfuD.i{s\- q,>\ | BUSINESS ADDRESS IN YARMOUTH 51a \.,- -rt'2Y S, ai{- L \, 7 E'r-.r(\ Ho O a'-13 MAII-ING ADDRESS Sq.rc JUN 16 Z0Z5 EMAIL ADDRESS \ rrSU e- (r\s\o C)a{'jsotr.t s€-a \*ttl!r l{l (rL I t< t..t)MANAGER/CONTACT PERSON \rt\r:"r \snr.nzrb TELEP uoNe + E:b- \\r.- \1'\L REoT IRI-I) OWNER NAME N.lc\.,.t, i\o ,".q\\1g1.g 5D'u-\*t-\rrr. I.IOME ADDRESS ?r \) \>n Rj Yrr. rr.:,i\ t\> o lr.'rl CORPORATION NAME (IF APPLICABLE)f\orrr-.t\'' \rro.,TFL. # -$\ Sf,"\- 1:q\ CORPORATION ADDRESS Sr5nc MAILING ADDRESS q.'\\t TAX ID (FEIN OR SSN)ItEOUlltt_D 1a3- -1"i.art 1 LICENSES RUN ANNUALLY FROM JULY I TO JLTNE 30. IT IS YOUR RESPONSIBIL ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY ruNE 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 To*n of Yurrnouth taxes and liens musl be paid prior to renewal or issuance ofyour permits Please check Compcnsation Affidavit. If not applicablc, plcasc cxplain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE appropriately if paid: yesgl no- nla- Under Chapter 152, Sec. 25C, subsection 6, the Town ofYarmouth is required lo hold issuance or renewal ofany license or pcrmit to operate a busincss ifa person or company does not have a Certiftcation of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers 2 Y N N ANYNEwCHEMICALSMUSTBEPRE-APPR0VEDBYTHEHEALTHDEPARTMENT. ./ RL,NEWAL APPLI('ATION y' NFW APPLICATION- APPLICANT'S SIGNATURE DATE: b ]ll').>l- OL s; The Commonwealth of Massachusetts Departm ent of I n du stria I Accidents Ollic e of I nv estig atio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lceiblv Business/Organi231lsn Name: \.k's.rv \\ \ \l,r(r) \(' Address: 5\1 f([L Zg Ciry/StareiZip 01r-12 Phone#: Sot 3\-\q\ 5 6 Busincss T1'pe (required) Retail RestauranVBar/Eating Establishment 7. ! Office and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing ll H l2 o ealth Care ther 0 .ji C> rr.ro\ i tSr\ r\,}'. r.J : \/Ar.t:.i\ t{.t *Any applicant that checks box #l must also fill out the section below showing lheir workers' compensation policy information...lf the corporate omcers have exempted themselves, but the corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. I am an employu that is providing workers' compensotion insurance for my empktyees. Below is the policf inlormation. lnsurance Company Name: C \l --r $ g C o.-- o...j5.ru--J \nsrr onv. \ Insurer's Address: 61. \\oq c.t<.1f C5- o\sotn Policv # or Self-ins. Lic. #Erpiration Date: -1- \- 2JL- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to securc coverage as required under $ 25.A ofMGL c. 152 can lead to the imposition of criminal penalties of a lure 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 fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of [nvestigations of the DIA for insurance coverage veriltcatiou. I do hereby certifl','er the pains and penalties of periury that the inlormation provided above is true and correct. Si ture Date 2J Phone #-5Dt c\L{'t- \1'\tr 5 Officiat use only. Do not write in this srea, to be completed by cirv* or town ollicial Permit/License # Phone #:Contact Person: 3flCiry/Town Clerk 4. ! Licensing Boardlssuing Authoritv (check one): 1flBoard of Health 2.n Building D€partment 5[ Selectmen's Oflic€ 6. Eother www.mass.govldia Are yo) an employer? Check thc appropriate box: t . Mzt am a employer with \ 5 employees { full and" or part-time).* Z. n t am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] l. E We are a corporation and its officers have exerciscd their right of exemption per c. 152, $ I (4). and we havc no employees. [No workers' comp. insurance required]*i +. I We are a non-profit organization, staffed by volunteers, with no cmployees. lNo workers' comp. insurance req.l tr Ciwi Srate/ZiD: \p({l(or*j (. c-s Clr'6\ Cilv or Town: Information and Instructions Massachusctts General Laws chapter 152 requircs all employers to providc workers' compensation for their employecs Pursuant to this statvle. an employee is defrned as "...evcry person in the service ofanother under any contract ofhire. express or implied, oral or written." At employer is detined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the rcceiver or trustee of an individual, partnership. association or other legal cntify, employin8 employees. However, the owner ofa 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 the grounds or building appurtenant thereto shall not bccausc ofsuch employment be deemed to be an employer." MGL chapter 152, g25C(6) also states that "every state or local licensing agency shall withhold th€ issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable €vidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for thc performance ofpublic work until acccptable cvidence ofcompliance with the insurancc rcquircmcnts of this chapter havc becrr prescntcd to the contracting 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 affidavit may be submitted to the Department of Industrial Accidents for confirmation ol insurance covcrage. Also be sure to sign and date the aflidavit. The affidavit should bc returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial 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-insured companies should enter their self-insurance liccnse number on the appropriate line. City or Town Officials Plcase be surc that the affidavit is complcte and printcd lcgibly. The Department has provided a spacc at the bottom of the alfidavit for you to fill out in thc event thc O{Iice of lnvestigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiylicensc applications in any given ycar, need only submrt one affidavit indicating current policy information (ifnecessary). A copy ofthe afiidavit that has been officially slamped or marked by the city or town may be provided to the applicant as proofthat a r,aiiii affidavii ;s orr filc lor iuture permils ur iicenses. A new alldavii 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 venturc (i.e. a dog license or permit to bum leaves etc.) said person is NOT rcquired 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 fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I -1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia -._/ EHIJEIEI' INSURED'S NAME AND ADDRESS VDAC TEIS IS A QI'OTE, NOf A POLICY WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QrrorB PRoF|LE - VERSTON 01 poLlcy NUMBER: (5S52rrB-4735p53 -A-25) . RENBWAT Op ( 6s 5 2rrB - 47 3 6p63 -A- 2 4 ) A/R (i7CrP) *MA f::1(rc:r \ (5><r',. U\C\ D \..'J r.) <)(-io'L\ Q>t{r:c.'c! ITARTINEIJLO & I'IORRIS INC DBA l,loLD DocToRs e \BA A&M PEST 572 ROITTE 28, !{AIN ST. I'NIT 2 I{EST YARI{OUTE }IA 02573 pOLlCy PERIOD FROM: 07-08-2s TO o7-08-26 TOTIIJ ESTII{ATED AN![I'AL STANDARD PR.BIII,II SPREIIII,u DISCOI'NT 0900-20 EXPEISE CONSTANT TERRORISM IOTA! ESTITIATED PRETIUU TAXES ArlD SURCEARGES DEPOSIT AldOI'lTf Dt'E 8110 NOIIE 338 209 914 4 375 9520 Employer's Liability Bl Limit $ INSURER: ACE AI{ERICAI{ IIISUTANCE couPA.lrY , . . . .,,, . ., *11'lT:1T :l :':B:,',ilill"JiXiTfl: Each Accident Policy Limit Each Employee ANIIUAI.LY S 9520 taar rrr*t,r,a *t': ** r.i r ra:r 500000 500000 s00000 pOLlCy NUMBERs ( 5s62rrB-473 5p53 -A- 2 s ) PENDING RATE CEANGE: uA DATE OF ISSUE:o5-14-2s rc OFFICE: ruD CEUBB 24u PRODUCER: BALDWIN XRYSrI}I ESER AtI 23iT2X ST ASSIGN:MA 9IORXERS COMPENSATION INSI'R.A.ITCE PLEN