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Home My WebLink About2025-26 Application Onlyqfs il$DEc ct ygr'LICENSE $Hrt,,4 -a3-9UV FEE: $ 150.00 OF YARMOUTH BOARD OF HEALTH 2025/2026 HANDLINC AND STORAGE OF TOXIC OR HAZARDOUS LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND R.ETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 PLEASE COMPLETE ALL QUESTIONS HEALTH DEPT NAME OF BUSINESS he IL BUSINESS ADDRESS IN YARMOUTH MrrrstA$fifi;:D c. BUSTNESSTEL. # gY 31q'3trtq SD Lanq pm& \uLot_. J.,lwn r J MAILING ADDRESS JNr\tg EMAIL ADDRESS LL REQUIRED MANAGER/CONTACT PERSON ba,ntel b,twttnt rereeuoNe+ ?Jq(ilo5 t Davr'al bvrnurl TEL.#11'+ 83bE;D? HOME ADDRESS CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS t1l ,furtt--TEL. # J4-rnl- June- MAILING ADDRESS lqrv+- TAX ID (FEIN OR SSN)REQUIRED 0q a't n tq3 LICENSES RUN ANNUAILY FROM ruLY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY ruNE 30. FAILURE TO DO SO WIL 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 agl liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes y' no_ nla- 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 of Workers Compensation insurance. As part ofrenewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Allidavit. Ifnot applicable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SA-FETY DATA SHEETS ON FILE ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THf, HEALTH DEPARTMf,NT. RENEwAL APPLTCATIoN Y/ N APPLICANT'S SIGNATURE NY t/ NY 1DATE PLICATION 6iEr;Er:t:=: REOUIRED OWNER NAME .A.The Commonwealth of Mossachusetts Deparfiienl of Industrial Accidents Offt ce of I nve stigati o n s I Congress Street, Suite 100 Bosto\, MA 02114-2017 www.mass.gou/dia Workers' Compensation Insurance Affidavit: General Businesses Print Form Business/Organization Name:Th uv1_ Address: CitylStatelZipl al Are you an employer? Check the appropriate box: l.! I am a employer with or part-time) . * 2. n I am a sole proprietor or partnership and have no employees working for me in any capaciry. ,zfNo workers' comp. insurance required] 3. E]' We are a corporation and its officers have exercised thei right ofexernption per c. t 52, $l(4), and we have no employees. [No workers' comp. insurance required]*' 4. I We are a non-profit organization, staffed by volunteers, with no ernployees. [No workers' comp. insurance req.] employees (full and/ Phone #:1 Businep Type (requlred) : 5. [fRetail 6. I Restaurant/Bar/Eating Establishment 7. ! OfEce and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9 Entertainment 10.! Manufacturing I l.E Hedth Care t2.E other c fir i9q6rl *A[y applicant that checks box #l must also lill out the section below showing their workers' compensition policy information. **lfthe corporate oflicers have axempted themselvcs, but the co.pomtion has other cmployces, a workers' compensadon policy is requircd and such sn orgatization should check box # L lnsurance Company Narne:_ I am an employer that is ptoviding wo*erc' compensalion insurance for my employees. Below b the policy information. Insurer's Address CitylstatelZip Policy # or Self-ins. Lic. # Expiration Date:- Aftach a copy ofthe wgrkers' compensation policy declaration page (showing the policy number and erpiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa hne up to $1,500.00 and/or one-year imprisonment, as wcll as civil penalties in the form of a STOP WORK ORDER and a Ene of up to $250.00 a day against the violator. Be advised that a copy of this staternent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Phone # the pains and pen alties ol perjury that the inloruration protided above is true and cotrecl te: )+l1 ?t) Ofliciat use onty. Do not h'rite in rtis area, to be completed by cily or town offrcial Issuitrg Authority (circle one): 1. Board of Health 2. Building Departnent 3. City/Towtr Clerk Contrct Persotr: PermiUlicense # 4. Licensing Board 5. S€lectmen's Oflic€ Phone #: City or Town: 6. Other - www.mass.gov/di! Applicant Inforqration Please Print Leeiblv Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workeis' compensation for their employees Pursuant to this statute, an employee is defrned as "...every pemon in the service of another under any contract of hirc, express or implied, oral or wrinen." An employer is defined as "an individual, partuership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives ofa deceased employer, or the receiver or trustee ofan individual, partnership, association or other legal entity, employing ernployees. However, the owner ofa dwelling house having not more than three aparfrnents and who resides therein, or the occupant ofthe dwelling house of another who ernploys persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deerned to be an employer." MGL chapter 152, $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 busiless or to construct buildings itr the commonwealth for any applicant who hss not produced acceptoble evidence of complisnce with the insurance coverage required." Additionally, MGL chapter 152, S25C(7) states'Neither the commonwealth nor any of its political suMivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirernents of this chapter have been presented 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. If an LLC or LLP does have employees, a policy is requted. Be advised that this aflidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. A.lso be sure to sign and dste the sflidavit The affitlavit should be retumed 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 Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departnent has provided a space at the bottom of the affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/Iicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiVlicense applications in any givel year, need only submit one aflidavit indicating current policy information (if necessary). A copy of the affidavit that has been o(ficially stampod or marked by the city or town may be provided to the applicant as proof that a valid ailidavit is on file for future permis or licenses. A new affrdavit mustbe fill€d out each year. Where a home owner or citizen i5 o$teining 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 affrdavit. The Office oflnvestigations 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or I-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 7/2010