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Home My WebLink About2025-26(h.n0 1tq5 LICENSE FEE $I50 g HU-Ls't8f8 TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LrcENsE Appl,rcArroN RECEIVTnCOMPLETE THIS APPLICATION AND RETURN IT \I'ITH THE LICEINTFEE PLE.ASE COMPLETE ,{LL OUESTIO),{S NAME O}' BUSINESS ?el.rsons l1o.t"* BUSTNESS ADDRESS rN YArurouru I 6fl,+ MATLTNG ADDRESS 5an o )uN 2 3 ?0?5 HEATTH DEPI BUSTNESS rEL. # 5oA -3Q +lLl7 "rrl B\', .tt \E -10. 2025 r n { io fL"LL'"ltS. .s e qfiql . c:ort1EMAIL ADDRF,SS (di. clf riit :D ANAGER/..NrACrpERSoN # B 1",' t-"ttb cos-e37- ;Asf RE()T]IRFD M TELEPHONE # RT-ot IRFD OWNER NAME rct* <o6 -)37- 5A/ CORPORATION NAME (IF APPLICABLE)6.oL ll,ll f. r'> t-cc rEL t .eoa-J37-5t6/ coRpoRATToNADDRESS RS lWu.^l<.s DrL, tL*t.L HA N1f MAILING ADDRESS *",ne LICENSES RLIN ANNUALLY FROM JULY I TO JTNE 30. IT IS YO[,'R RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LINTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED, A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENINC. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately it paid: yes_lzl no- na- Under Chapter I 52, 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 ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affidavit. If not applicable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ZY/N ALL SAFETY DATA SHEETS ONFILE ,/ YN ANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. //hlPz--"-APPLICANT'S SIGNATURf 7 7r7 v-DATE HoMEADDRESS 96 Hu-^J,uJlcz.q' D lL,-,J HA d*t-f twe rAX rD (FETN oR SSN) REOUIRED g6' O TflO)tO ./RFNFWAI APPI.TCATION r./NEW APPLICATION 4rr/E e1 The Commonwealth of Massachusetts Department of I ndustrial A ccide nts Olftce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02IlI-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses t:til A licant Informati n Business/0rganization Name address: ?18 t1aro6, Please Print Le bl I CitylStatelZip:nr Phone #:f|7 Business Type (required): 5. EJ Retail 6. ! Restauranttsar/Eating Establishment 7 8 Office andTor Sales (incl. real estale, auto, elc.) Non-profit 9. ! Entertainment l0 ll Manufacturing Health Care l2.E other *Any applicant that checks box #l musl also fill out the section below showing their workers' compensation policy informalion.**lfthe corpomte officers have exempted themselves. but lhe corporation has other employees, a workcrs compensation policy is required and such an organization should check box #1. Are you an employer? Check the appropriate box: t . ( I am a employer ntn 30- 3{rmployees (full and,' or part-time).* I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4). and we have no employees. [No workers' comp. insurance required]+ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 2 3 4 I am an employer that is ptoviding workers' compensotion insurance for my employees. Below is the policl, informotion. lnsurance Company Name:Cc,ve R.St Sacvrces l-l,C Insurer's Address Ra B"x Ssaall-1&)\ Br*'"hca l?A ou?f, Policy # or Self-ins. Lic. #o lqMo3{5iZ txf Expiration Date Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penaltics ofa finc up to $ I,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 5250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of I nvestigations of the DIA for insurance coverage verihcation. I do hereby certifi, under the pains and penalties ofpetury th the inlorm ion provided above is true and coffecL at Date ,7 Issuing Authority (check one): lflBoard of Health 2.E Building Department 3.8 Ciry/Town Clerk Permit/License # 4. E Licensing Board 5[ Selectmen's office 6. Eother Contact Person: www.mass.gov/dia Cityr5131.77;O' Olficial use only. Do t or te?ite in lhis area, lo be completed by ci.!* or town olrtcial. Phone #: Citv or Town: Information and Instructions Massachusetts General Laws chapter 152 requires all employcrs to provide workcrs' compensation for their employees Pursuant to this stalute, an employee 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 of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee ofan individual, partnership. association or other legal entity, employing employees. However, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house ofanother who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtenant thercto shall not because of such employment be deemed to be an employcr." MGL chapter 152, $25C(6) also states thal "ev€ry state or local licensing agency shall withhold the issuance or renewal of a license or permit to opcrate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insuranc€ cov€rage required." Addirionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its polilical subdivisions shall entcr into any contract for the performance of public work until acccptable evidcnce ofcompliancc with the insurance requirements of this chaptcr have becn prcscnted to th.' contracting authoritv." 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 ofinsurance. 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 rs required. Be advised thal this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coveragc. Also be sure to sign and date the affidrvit. Thc affidavit should be returned 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 numbcr listed below. Self-insured companics should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is completc and printcd legibly. Thc Dcpartmcnt has provided a spacc at the bottom ol the affidavit for you to fill out in thc event the Officc of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given ycar, need only submit one affidavit indicating cunent policy information (ifnecessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affrdavit is on file fcr future permits or licenses. A new afldavit 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 liccnse or permit to bum leavcs etc.) said pcrson is NOT required to complete this affidavit. The Office of Investigations 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 Lafayelte City Center 2 Avenue de Lafayette, Boston, MA021l1-1750 Tel. (857) 321-7406 or l-S77-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia lnsuror lO No (s): 3lt355 MA Retail Merchanls WC Group lnc PO Box 859222-9222 Braintroe, MA 02185-0000 Workers Compensation and Employers Liability lnsurance Policy Carrier Policy #:Policv Period 014005035537125 0'l lO1 12025 lo 01 101 12026 lnformation Page FEIN; 001563220 Renewal Policy Canier Prior Policy #: 014005035537124 Itsm 'l:Named lnsured and Address Aq€ncY Book Hill Farms LLC Peterson's Markot 918 Maln Strest Yamouthport, MA 02675 Dowling & O'Neil lnsuranco Agency PO Box '1990 Hyannls, MA 02601 Other Workplaces Not Shown Above: No Other Workplac€s for this Policy Additlonal Named lnsured: See Additlonal Named lnsureds if Applicablo Typs of Businels: Limited Liability Company (LLC) Rlsk lD: 1242578 Un.mploymont lD #: Federal lD#: 001563220 NCCI / Bursau #: 34355 Fll€ #: 014005035537125 Itom 2. Pollcy Prrlod The policy period is from 12:0'l AM on 01/01/2025 to 12:0'lAM on 01/01/2026 based on the insured's mailing addr6ss tim6 zone- Itam 3, Coverage: A. Workers Compensation lnsuranco: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employsrs Liabilitflf,srrrance: Part Two of th€ policy applies to work in each state listed in ltem 3,A. Th6 limits of our liability under Part Two are: Bodily lnjury by Accident $ 500,000.00 each accident Bodily lnjury by Disease $ 500,000.00 policy limit Bodily lnjury by Disease $ 500,000.00 each employeeC. Other States lnsurance: D. This policy includes these endorsements and schedules: wc000000c(01/15), wc000310o, wc000406(/), wc000414A(01/19), wc000422c(01t21), NOE(01/01), WC200102(01t't4r,wc200301(04i84), wc200302A(09/08), wc200303D(08/10), WC2003068(06/13), WC200405(06/01), WC2OO6OIA(O7iO8) Item 4: Premium The Prcmium for the policy will be d€termined by our Manual of Rulos, Classmcations, Rat€s and Rating Plans. All information required belowis subjoct to verilication and change by audit. Classific€tions Code #Premium Basis Total Estimated Annual Remuneration Rate P6r $100 of Remuneration Estimated Annual Premium Sse Schedule of Oporations on Following Page(8) Mlnimum Premlum Proralod Premium Eltlmated Annual Premlum ExDonso Constant $ 268.00 $ 24,385.00 lssuing Oftice: 35 Brainkee Hill Office Park Ste 206 Braintr€e MA 0218t0000 $ 0.00 Date Printed 12-27 -2024 $ 24.385.00 Countersigned by R"l14 Pag6 1of 1 Fom # WC 00 00 01 C(Ed.0s/17) O Copyright 2013 National Councll on Componsetlon ln5umnc6, lnc. Ajt RithCs R€soNed.