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Home My WebLink About2025-26s$tP r'?fl25 )T;Ii.l:jnNr gAqb . LICENSE FEE SI50 /rilHN-a3-$v7 OF }'AR}IOU'I'H BOARD OF HE.{I-TH D STORAGE O}'TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH TTIE LICENSE FEE BY JUNE 30. 2025 PI,EASE Co ALL OUESTIONS NAME OF BUSINESS BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS EMAIL ADDRESS RESLIREDMANAGE ONTACT PERS €rmu "rr^rrr rur. o .39 )7Llt. \) f ,ur.o5f,08a1ll J\O 'L1u TELEPHONE #"50b\nt 21>t BE]O.IJIBED OWNER NAME HOME ADDRESS 6 CORPORATION NAME (IF CORPORATION ADDRESS APPLICABLE) MAILING ADDRESS tl -7 ) LICENSES RUN ANNUALLY FROM JTILY I TO JUNE 30, IT IS YOUR RESPON SIBILITY TO RETTIRN THE COMPLETED APPLICATION(S) AN'D REQUIRED FEE(S) BY JLINE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LINTIL THE REQUIRED APPLICATIONS(S) AND FEE(S)ARERECEIVED'AHEARINGBEFORETHEBOARDoFHEALTHMAYBEREQUIREDPRIOR TO REOPENINC Town of Yarmouth taxes and liens must be paid prior to renewa I or issuance of your permits. Please check Com ensation AffidaYit. lf not aPPlicable, plcase cxplain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SIIEETS ONFILE appropriately ifpaid: yes- no- nla- Under Chaprer 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any t,a.naa o, p'"rai, ,o operate a business ifa person or company does not have a Certification of Workers Compensation inru.una". A. pun ofihe renewal or issuance ofyour permits, you must complete the €nclosed workers NY ANY NEW CHEMICALS NIUST BE PRE'APPROVED BY THE HEALTH DEPARTMENT' RENEWALAPPLICATION- NEWAPPLICATION- N ( APPLICANT'S SIGNATURE DATE ! rAx rD(FErN on ssNlB@ED TEL. fzrils The Commonwealth of Massachusetts Dep artm en t of I n du strial Accidents O/fice of Investigations LafaYette Ciq' Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass,gov/dio Workers' Compensation Insurance Affidavit: General Businesses ,fl Address: Business/Organization Name bdold City/Sta zip: 6i Phone #:u0'6qb 21 Ll Business Tvpe (required) 5 6 Retail Restaurant/Bar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. 9. 10. I l. Non-profit Entertainment Manufacturing Health Care t2.[YLother s\ 0 *Any applicant that checks box #l must also fill out the section below showing their workers' compensation policy information.**lf the coaporate 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 a sole propnetor 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 exerciscd their right of exemption per c. 152, $ l(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.] Ar€ 4E 2 -l Check thr appro *ith tl e tertr xbonaelorepmpv lt-I o e Sc anI)pI am a employe or part-Iime). * I tm an employer that is providing workers'sation insurance fitr nty employees. Below is the policf informotion. -To 5 5 .d City'State Zip:0({\cr 0l Policy # or Self-ins. Lic. #C+tI)p^sjs+)41 Expiration Date D- Attach a copJ- of the workers' compensation policy declaration page (showing the policy number and expiration date). Failurc to secure coverage as required under $ 25A of MGL c. I 52 can lead to the imposition of crintinal pcnaltics of a finc 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 forraarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains tnd es of peiury that the inlorntation is ttuz snd correlbfizt \ DaatLtre ne#5AA,3 )1)-- Ollicial use only. Do nol wite il this area, to be completed by city or town oJficial' 5f! Selectmen's offic€ 6. flother Permit/License # Phone #: 3.E Cirr.-'/Town Clerk 4.ELicensing Board Contact Person: City or Town: tssuing AuthoritY (check one): l[Board of Health 2.E Building Department wr/w.mass.gov/dia Applicant lnformation Please Print Leeiblv ?bo , tull( lnsurance Company Name: Insurer's Address: above Information and Instructions Massachusetts General Laws chapter 152 requircs all employers to provide workers' compensation for their employees Pursuant to this statute, an errrploJae is detined as "...every person in the service of another 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 olher legal entity, emplolng 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 thc grounds or building appurtenant thercto shall not because of such employ.rnent be deemed to be an employer." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall t'ithhold the issuance or rcnewal of a license or pcrmit to operate 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 pcrformance ofpublic work until acceptable cvidcnce ofcompliance with the insurance requircments ofthis chapter have been presented to the contracting authoritv " .4.pplicants Please till 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 required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coveragc. Also be sure to sign and date the aflidavit, The affidavit should be 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 Department at the number listed below. Self-insurcd companies should enter their self-insurance licensc number on the appropriate line. City or Town Officials Please be surc thal the affidavit is complele and printed legibly. The Department has provided a space at the bottom of the alfidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicanr. 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 pcrmit/licensc applications in any given year, need only submit one affidavit indicating currenrpolicy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prcofthet a valid affidavit is on filc for futurc permits or licenses. ,A^ ne.v affidavit must be filled out each year. Where a home owner or citizen is oblaining 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 thisaffidavit. The Office of Investigations would like to thank you in advancc lor your cooperation and should you have any questions,please do not hesitate to give us a call The Depanment's address, telephone and thx number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette. Boston, MA02lll-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 www.mass.gov/diaForrn Revised 7 2019