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Home My WebLink About2025-26ct.No' ts77 so 81fl/i./-zq-zf <€., S I NAME OF BUSINESS R,v icrcracSr-r,a- BUSINESS ADDRESS IN YARMOI-ITH S'Sh.rne Drruc MAILING ADDRESS -arLrnc LICENSE FEE S OUTH BOARD OF HEALTH 202s1202 RAGE OF TOXIC OR ILAZARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JT-INE 30, 2025 BUSINESS TEL. #9 REGIEOI/trD JUL 2 8 2025 TOWN OFY nltttrLlNd[Frb sr EMAIL ADDRESS R.B, BESIiIEED MANAGER/CONTACT PERSON cL(e rrrrpHor.rn*(to 11) {rgt - llaa RF,OUIRF'N OWNER NAME TEL.# HOMEADDRESS CORPORATION NAME (M APPLICABLE) CORPORATION ADDRESS MAILING ADDRESS <,ar^Q TA-X ID (FEIN oR SSN) REOUIRED k 8 -3t5 ox 4R LICENSES RL]N ANNUATLY FROM JULY I TO JT]NE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JI]NE 30. FAILI]RE TO DO SO WLL RESI.,'I-T IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED A?PLICATIONS(S) AND FEE(S) AIIE RECEI!'ED. A HEARING BEFORE THE BOARD OF TIEALTH MAY BE REQUIRED PzuOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check aoorooriatelv ifoaid: ves no nla Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany 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 explair: REGISTRATION FORM SIGNED AND COMPLETED CHECK AN'D WORKERS COMP AFFIDAVIT ENCLOSED YN ALL SAIETY DATA SHEETS ONFILE ANY NEw CHE1VtrCALS MUST B; PRE-APPROVED BY TM M.{TTU ONTARTXIENT. APPLICANT' S SIGNATLTRE DATE 7hr PLEASE COMPLETE ALL OI,'ESTIONS RENEWAL APPL ICATION I-/NEWAPPLICATION- The Commonwealth of Massachusetts Departm ent of Industrial Accidents OfJic e of Inves tigat io n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affi davit: General Businesses ,:l Business/Organization Name:q rvt V'(x ?( \({+ Address: 3Ll Sc'v"' 1 )nrr*-ov'c citylstatelzip:A Phone #: (SOg)3qk-L?88 *Any applicanr thal checksbox #l must also fill out the section below showing their workers' compensation policy **lfthe corporate officers have exemp organization should check box #l. ted themselves, but the corporation has other employees, a workers' compensalion policy is required and such an ou an emplo-ver? Check the appropriate box: I am a sole proprietor or partnership and have no employees working for me ir: any capacity. [No workers' comp. inswance required] 3. E we are a corporation and its officers have exercised their right of exemption 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 employees. [No workers' comp. insurance req.] employees (full and/ Are v,#I am a employer with or part-time).* 2. Business Type (required): Retail Restaurant/B arlEating Establishment Office and/or Sales (incl. real estate, auto, etc') Non-profit Entertainment Manufacturing 5. 6. 7. 8. 9. l0 I l.I Health Care tz.Other roviding workers' compensation insurance for my employees. Below is the policy information'I am sn ernployer that is P Insurance Company Name lnsurer's Address 14oc )-.-Don T)odr,r..!-\\( citylstate/zip Policy # or Self-ins. Lic. #c()3 lao (ooC Expiration Date: Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and erp iration date). Failure to secure coverage as required under $ 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 andior one-ye:u 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 Office of Investigations of the DIA for insruance coverage verification. I tlo hereby certdy, under the pains and penalties ofperjury that the information provided above k true and correct. Sisnature:Date Phone # Ollicial use only. Do not write in this area, to be completed by city or town olJicial. Issuing Authoritv (check one): lflBoard of Health 2.E Building Department 3.E Ciry/Town Cl€rk 4. E Licensing Board Contact Person:Phone #: Cig' or ToBn:Permitllicense # 5[ Selectmen's Office 6. Eother wtvr.mass.gov/dia Applicant Information Please Print Legiblv r