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Home My WebLink About2025-26Y,{ lr!-!-" LICENSE FEE: $150.00 \O Causl-\ TOWN OF YARMOU-IH BOARD OF HEALTH 202412025 HANDLING AND STORAGE OF TOXIC OR HAZARDOU LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE !-EE BY JUNE 30,2024 PLEASE COMPLETE ALL OUESTIONS BUSINESS ADDRI]SS IN YARMOUTH qasNAMEoFBUSTNusQa<\--. &ae|-. H.I-\€s BUSTNEss rer-. * 5DT ff$flrttt cL r r-bu tl MAILING ADDRESS Sc-^-c*o- ato.* EMAIL ADDRESS Pr,*<-sl, A Jh nrr-US. Co r/^\ MANAGERjcoNro.r ru*ro,n?r ,}.s\. PaU owNER NAME nBOutnrfB\ wb i.A HoNrsrsl.5oS Ury, Q Sg? HOME TEL. #5cfl r,sG asE\ I.L C HOME ADDRESS CORPORATION NAME (IF APPLICABLE)Blu.hiat ft."L* CORPORATION ADDRESS f,p*<-3oo MAILING ADDRESS S CF,r\--<-- 0,J.1 LLC TEL. # 9e St 5lf 05 LICENSES RLIN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WIL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LTNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORT THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO RTOPENING. Town of Yarmouth taxes arf liens must be paid prior to renewal or issuance of your permits. Please checkno nlaappropriately if rraid yes 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 Cerlification of Workers Compensation insurance. As part ofrenewal or issuance ofyour permits. you must complete the enclosed Workers Compensation Affidavit. If not a licable lease ex lain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED YN ALL SAFETY DATA SHEETS ON FILE N ANY Nf,W CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION APPLICANT'S SIGNATURE DATE NEW APPLICATION rAx rD (FEIN on ssNl REQUIRED t ne Lommont9eaun oJ lvtussucnuselfs D epartm ent of I ndu strial A ccidents Offi c e of I nves tigatio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses {tu Applicant Information Please Print Leeiblv Business/Organization Narne: Bluebird Parker Hotel LLC Address:'192 South Shore Dr CitylShre/Zip South Yarmouth MA 02664 phone #: 508-694-7688 Business Type (required): 5. ! Retail 6. ! Restaurant/Bar/Eating Establishment 7. E Office and/or Sales (incl. reat estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing I l.! Health Care l2.E other Hotel iAny applicant thal checks box #l must also fill out the section below showing their workers' compensation policy information. r*lfthe corporate officers 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 employer that is providing worken' compensalion insurance for my emplol-ees. Below is the poliq, information. lnsurance Company Namc. Technology lnsurance Company lnsurer,s Address. 167 S River Rd. Unit 10 Bedford, NH 031 10 Policy # or Sclf-ins. 11". g TWC4626064 Expiration Date: Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coveragc as rcquired under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-ycar imprisonment, as well as civil pcnalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Bc advised that a copy of this statement may be forwarded to thc Officc of Investigations of the DIA for insurancc coveragc verification. I do hereby certify,urrdct tlt # and penalties of perjury thot the inform ion provided ot'e s ttue ond correct. Datc (0 OfJicial use only. Do not write in this area, to he completed h;, ci4t or town official. Permit/License # Phonc #: 3l--'l City/Town Clerk 4.ELiccnsing Board Citv or Town: Issuing Authorig (check one): lflBoard of Health 2.D Building Departmcnt5[ Selectmen's OIfice 6. Eother Contact Person: I Are you an employer? Check the appropriate box: l. E I am a employer with 4 employees (full and/ or pan-time).* Z. E t am a sole proprietor or parmership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right of exemption per c. I 52, $ I (4), and we have no employees. [No workers' comp. insurance required]*l 4. ! We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] City/State/Zip: 511t2026 BLUEPAR-01 CERTIFICATE OF LIABILITY INSURANCE 5tgt2025 IMPORTANT: lf the certificate holder is an AODITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WAIVED thls certificate does not confer ect to h terms nd nd ti n5 theof cerla n tes alren mendorsenl.mestate nl nsubjicypolpolmaylequ ts thto ificaterth ends uch rsemen INSIJREO AEencyBoufford lnsuranco 167 S River Rd. Unit Bedford, NH 03110 Bluebird Parker Hotel LLC 110 Hartwell Rd Suite 300 Lexington, MA 02421 fI3,rnE , e"l, (603) 623-zzz8 fiffilr" francis@bouffordins.com INSURER(S) AFFOROING COVERAGE sunen a , Technolggy lnsulance Company [il, na,1ooa1 ezs-zzso IN IN Francis Quispe SURER C INSURER B IIISURER E COVERAGES CERTI TE NUM REVISION NUMBER: ADOL THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAT.IED ABOVE FOR THE POLICY PERIOD INDICATEO, NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUiTENT WITH RESPECT TOWHICH THIS CERTIFICATE I\,!AY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LIMITSINSRTYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY I curus-ueoe ! occu^ GEN'L AGGREGATE LIMITAPPLIES PER: "ou"" f ]35"o, OTHER LOC OAMAGE IO RENTEO AU'OMOBILE LIABILITY OWNEDAUTOS ONLY HIRED AUTOS ONLY AUTOS ONLY SCHEOULED AUTOS COMBINED SINGLE LIMITaccd€nlL EXCESS TIAB DEO RETENTION $ OCCUR CLAIMgMADE E,\cH occqE&ENcE AGGREGATE $ A WORXERS COMFENSANONAIiO Ei'PLOYERS' IIABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER,IMEM BER FXCL UDF D' If E]5t1t20?5 5t1t2026 THx E,L EACH ACCIOENT E,L.Q!9EASEJfAEUIIQYE E,T, OISEASE. POLICY LIMII 5 1,000,000 1,000,000 1,000,000 OESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES {ACORO l0l, Adlilionar Remarls Sched u 1., m.y b. .ttachod af moro spac. i! r.q!ned)reference location: 192 S Shore Or. South Yarmoulh. MA 02664 CERTI CANCELLATION O 1988-2015 ACORD CORPORATION. All rights reserved The ACORD namo and logo are regist€rad marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.Town of Yarmouth 1145 Route 28 South Yarmouth, MA 02664 f* dT-AUTHORIZEO REPRESENTATIVE ACORD 2s (2016/03) --ACORD i+IIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIScERTtFtcATE DoEs Nor AFFtRMATtvELy oR NEGATtvELy AMENo, ExrENo oR ALTER THE covERAGE AFFoRDED By rHE poltctEs BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER. holder in lieu ot P= EACH OCCUAREiICE MED ExP (Anv ono osrsonl PERSONAL A ADV INJURY qE!E@!qqBE!4IL PRODUCIS. COMP/OPAGG -L -LI -L .L L E r I ! _$ ! TWC4626064