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Home My WebLink About2025-26Ch.No. ZtSo RSce/ FFll:: $ I 50.00 'rowN oF yARMou'H B()ARD oF HEALTH 8&t 202512026 HANDLIN(; AND STORAGE OF TOXIC oR HAZARDOUS MAT LICENSE APPLICA'TION BHHM.?3- IA3LI k8o t Z0?5 I l( lrNSIl {-i#i Pl.lrASF. COMPT-tr l E n Ll. Qt ills I loNS Iflaco, €scmllro PI,EASE COMPi,E]'E 'I-HIS APPI,I('A]'ION AND RE'[TIRN IT WII'H'THE LICENSE FEE IIY .llrNE .]0. 2025 NAMF_ OF BIJStNftSS Platinum Auto Service, lnc BI ]SINF-SS ADt)RtiSS IN YAITMoIIIII MAILIN(i rrpont,sS 27 Commercial Street, South Yarmouth, MA 02664 LMA I I- A DI)RLSS service@platinumautoservice.com llt rslNLSS rl'l-. # (508)760-2807 RrretruiEI) MANAGF.R/coNTACT pERSoN Brianna Esposito I ItLI:pl t()NL # (508)760-2805 R t:( )l IRED OWNITR y4y6 Jason D. Frazier HoMt. ADDRUSS36 Cocheset Path, West Yarmouth, MA 02673 I'l_.# (508)694-5027 CORPORAI'ION NAMt] (I F APPI,ICABI,E) CORPORA'I'ION ADDRESS I EI,. # MAII,IN(i A DI)RESS I AX ID (l-'lltN on SSNt REQ t[RED 51-0497826 t,ICI]NSES RUN ANNUALLY FROM J(]I-Y I I'O.IUNE 30. IT IS YoI.JR RT'SPONSIBILII'Y TO RETI.JRN THE COMPI.ETED APPLICATION(S) AND REQI.]IRED ITEE(S) BY JUNE ]0. I.AILURE TO DO SO WILL RESULT IN CI,OSURF, OF YOUR ESTABI,ISHMENT I]N'IIT, THE REQUIRED APPLICATIONS(S) AND FEE(S)ARt-. RIICEIVFID. A HEARING BEITORE'filE BOARI) Ot-' HtrAl.Tll MAY BE RI-.QUIRED PRIOR.I'O REOPENING. Town of Yarmouth taxes and liens musl be paid prior lo renewal or issuance of your permits. Please check appropriately iipaid: yesy' no n/a_ Under Chapter 152. Sec. 25C. subsection 6. thc l own ol-Yannouth is rcquired to hold issuance or renewal of any license or permit to operale a bLrsiness if a person or company does nol have a Certification of Workers Conrpensation insurance. As part ol renewal or issuance ol'your permi(s. vou musl complete the enclosed Workers Compensation 4$dxn!! lf not applicable. please explain: Rll(i ls l ltA I l()N I,ott M slcNF_t) AN I) ('oMpt.[t t:t)('lll,('K ANI) WORKlrltS lI lrN( 1.()Slll) ALL SAFEl'Y DAl'A SHF]E]'S ON IiII-t YN ANY NDW CHf,MICALS Mt]S'I'BI] PRE.APPROVED BY THE HEALTH DEPAR'I'MEN1" Rt]Nt]WAL APPI,ICAI-ION y' A PPI,ICN N]"S SICNA URE DA-I.t: 06t17 t2025 L N EW ICATION The Commonwealth of Massachusetts Depa rtmen t of I n d u strial A ccide nts Ollice of Investigations Lafayette City Center 2 Avenue de Lafiyette, Boston, MA 02111-1750 www.mass.gov/dio Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: PlRrrNUq nuto SEQy\CE .tNC. Address: L'l COT.TUEA.L\RL STREET ciry/stare/zip: s.\hQNIotLf\{, M A c.zral2+Phone #: (5b8) rr,O.ZSOf Are you an employer? Check the appropriatc box: l. ! I am a employer *'ith ? ? employees (futl and/ 2 J or parl-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 ofexemption per c. 152, $l(4), and we have no employees. [No workers' comp. insurance required]** 4. ! We are a non-profit organization, staffed by volunteers, with no cmployees. [No workers'comp. insurance req.] *Any applicantthat checks box #l must also fill out the seciion below showing their workets' compensation policy information. r*lfthe corporate officers have exempted themselves. but lhe corporation has other employees. a workers' compensation policy is required and such an organization should check box #1. I am on employer thst is providing workers' compensttion insurunce for my emphyees, Below is the policy infbrmution, Insurance f ompany Name: MYI QETR\L MEPI-HqNTS \NIL r\ \O \\t ( Insurer's Address: P.O. BCrX 85olZ22.qzz2- ( rly Slxle Zrp: W Policy horSelt-ins Lic H Ol+O69O30qbStZS Expiration Date: rLElNe\K \l t l2.ozt" Attach a cop] of the 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 penalties ofa hne 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 ofthis statement may be forwarded to the Oflce ol Investigations of the DIA for insurance coverage verification. I do hereby cert,ify, under the pains and penalties of perjury that the informotion provided above is true and correct. S tL[e Datc ne# Oflicial use only. Do not b,rite in this area, to be completed by ciy or rown oflicial. Citv or Town:permit/License # lssuing Authority (check one):l[Board of Health 2.! Building Department 3.E Ciry/Town Clerk 4.ELicensing Board5n Selectmen's Office 6. lother Phone #:Contact Person: www.mass.gov/dia Apolicant Information Please Print Lesiblv Business Type (required): 5. ! Retall 6. ! Restauranttsar/Eating Establishment Z. ! Office and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing I l.! Health Care r2.f Other AUrETI\rGT\VE TSDF,) r o . ? f\ 6-r Information and Instructions Massachusetts Gencral Laws chapter 152 requires all employers to provide workcrs' compensation for their employees Pursuant to this statute, anemployee 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 lruste€ ofan individual, partnership, associalion or other legal entity, employing employees. However, the 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, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such emplol.rnent be deemed to be an employer." MGL chapter 152, \25C(6) also states that "everl" state or local licensing agency shall withhold the issuance or rencwal 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 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 pcrformancc ofpublic work until acceptable evidence of compliance with the insurancc rcquircrnents of this chaptcr havc becn prescnted lo thc contractlng nuthority." Applicants Please fill out the workers' compensation atldavit 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 is required. Be advised that this affidavit may be iubmitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the af{idavit. Thc aflidavit should be retumed to the city or town that the application for the permit or license is being requested, not lhe Department oflndustrial Accidents. Should you have any questions regarding lhe law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insurcd companies should enter their self-insurance license number on the appropriate line. City or Town Officials Plcasc be sure that thc aflidavit is completc and pnntcd lcgrbly. The Dcparlment has provided a spacc at thc bonom ofthc affidavit for you to fill out in the event the Oflicc of Investigalions 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. [n addition, an applicant that must submit muliiple permiVlicense applications in any given ycar, nccd only submit one aflidavit indicating current policy information (ifnecessary). A copy of the aflidavit that has been olficially stamped or marked by the city or town may be provided to the applicant as proofthat a valid allid4vit is on tile for filture permits or licenses. A new affidavit 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 venhge (i.e. a dog license or permit to bum leaves etc.) said pcrson is NOT required to complete this affidavit. The Office of Investigations would likc 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 Offi ce of Investigations Lafayette CitY Center 2 Avenue de LafaYette, Boston. MA0211l-1750 Tel. (857) 321-'1406 or 1-877-MASSAFE Fax (617) 727-7'749 www.mass.gov/diaForm Revised 7i2019 . ,_r *ACC)Rf)1 v27 t2024 iHIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER, IMPORTANT: l{ the cerliricate holdsr is an AODITIONAL INSURED, the policy(ies) must be endorsed. lf SUBROGATION lS WAIVED, subject to the terms and conditions o, lh6 policy, certain policies may require an endorsemenl. A statement on this cerliticate does not confer righls to the certificate holder in lieu ot such endorsement(s) Association Members lnsuran@ Agency 80 Willow Road Nahant. MA 19080 INSUREO Plalinum Arrto Service- lnc. 27 Commercial Stre€t S. Yarmouth. MA 026 CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE NUMBER: 2COVERAGES REVISION NUMBER: 1 THIS IS TO CCNITV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATEO NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUAJECT IO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE AEEN REDUCEO BY PAID CLAIMS aISi TYPE OF INSURANCE io6l',sllBn-POLICY EFT POLICYEXP COT'TERCIAL GENERAL IAAIL|TY ctarMs-MAoE occuR EACH OCCURRENCEDaMaCaioFENiE-IRE!{lqE (E?!!cu(e!!E MED ExP (Anyon6o]6ls) PERSONAL & AOV IruURY ta*a*aoo*aoora i 1 t! GEN'L AGGREGATE LIMITAPPLIES PER PoLrcY 5$o; Loc PRODUCIS. COMP/OP AGG ! OTHER AIJTOMOBILE LIABILITY COMBINEO SINGLE IIMII , lE? lllidenll BODILY INJURY (P6. pe6on ): SCHEDUTEO NONOWNED BoDILY INJTJRY (Por a(d1l|| (Pd a@d€nll EXCESS LIAB c 9! 999!3!E!S! AGGREG,qIE S 'I RETENTION WORXERSCOMPENSATION x !r4ru!E-ANO EXPLOYERS' LIABITI'YI aw enoenreronnanrNER/ExEcurrvE OFFICEFI]MEMAER EXCLUDEDT(r.od.tory rn Ntl) ll yes o€s.nDe under 01101D025 01t01t2026 [ *,0 E E E EACHACCTOENT L 3l@_0@@ o,".0.. , .o .u",o".! s 166,696.66 DTSEAS€ -POLTCYlrMrr $ 500.000.00 OESCRIPTION OF OPERATIONS / LOCATIONS / VE HIC LES (ACORD 101 , Addilion.l Rem67l! Schsdule. m.y b. afl..hed il hore sp..€ is r.quired) CERTIFICATE HOLDER CANCELLATION SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION OATE THEREOF. TIOTICE wlLL BE DELIVEREO INACCORDAiICE WTTI TTIE POLICY PROVISIONS, Town Of Yarmoulh 1146 Route 28 South Yarmoulh [rA 026M "e;ir% @ 198E-2014 ACO The ACORD name and logo are .ogistered marks of ACORD RD CORPORATION. All rights reserved. PHONE lAlC, No-Ed ADDRESSI FAX II'SUFE R{S) AFFORO ING COVERAGE Ugr]RERl l,rA Retail Merchanls WC Group Inc. INSUiER B !4!c r INSURER C rysuRER O INSlJRER E II{SURER F 014005030965125 ACORD 2s (2014/01)