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Home My WebLink About2025-26PLEASE COMPLETE ALL OUESTIONS NAME OF BUSINESS €D An,oB SrlllM-a s-n th (es; r50t'36 0 LICENSE FEE $I50 N OF YARNIOU'I'H BOARD OI' HEAI,TH AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS I,ICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 r llr rs 7- tfir BUSINESS ADDRESS IN YARMOUTH BUSINESS TEL ?ss 1o.,'*PA YnNnna,ua lt4a MAILING ADDRESS 5en<- r.={rlsu v l_=19 SE,D 302025ro 202512026 HANDLIN HEAITH DEPI UJ EMAIL ADDRESS aPe co ) e",tr ;tl @) ino; l, cou B[.qtIED MANAGER/CONTACT PERSON 6*r,s1in TELEPHONE #sot- 367- lr"t{ ER NAME 6M 6'.4t^)-r.roKbr- 3l)- rct(B.E,QI]IBT,DOWN HOME ADDRESS JA ,\^L CORPORATION ADDRESS- CORPORATION NAME (IF APPLICABLE)-TEL. # MAILING ADDRESS gqr< <2> P.</,,ttOC.S LICENSES RLN ANNUALLY FROM JULY I TO JTNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 10. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARI RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPE,..'ING Town of Yarmouth taxes appropriately ifpaid: ye Compensation Affidavit. lfnot applicable. please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE A]\IY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEwALAppt-tcerrou,/ NEwAppLICATIoN- and,[ens must be paid prior to renewal or issuance ofyour permits. Please check s r/ 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 -{ Y APPLICANT'S SIGNATURE DATE 4-3o.zr rAx rD (FEIN oR ssN)BBEUIRED N N The Commonwealth of Massachusetts D epartme n t of I n d ustrial A cc ide nts Ollice of I nvestigatio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses I Ca^-Business/Organization Name: Address: 1(3 A-<-;w PL CitylSrarclZip >An+r,"IzIA m^ {zli{pnone*: lV6- 3ll" l8k Ar€ you an employer? Check the appropriate box: t.E I am a employer with employees (full and/ y'r part-rime). * 2.6 t am a sole proprietor or pannership and have no J 4 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]* We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. E Retail 6. E Restaurant tsar/Eating Establishment 7. 8. 9. l0 ll t2 Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing o ealth Carether fprtm *Any applicant thal checks box #l must also fill oul the section below showhg their workerc' compgnsation policy informadon. *+lfthe corporate officers have exempted themselves. but the corporalion has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance lor my employees. Bektw is the policf information. lnsurance Company Name Cityt51ut",'r.O Policy # or Self-ins. Lic. # Expiration Date Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to sccurc covcrage as requircd 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 tbrm of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be adYised that a copy of this statement may be forwarded to the Ofltce of Investigations of the DIA for insurance coveragc vcrification. I S do hereby certify, unde the pains and penalties of perjury that the information provided above is l|ue dnd correcl Date 3 o'z Phone #fl)f" 367'/flr Permit/License # Phone #: 3.E Ciry/Town Clerk 4. E Licensing Board City or Town: lssuing Authority (check one): lflBoard of Health 2.E Building Department 5! Selectmen's ofiice 6. Eother Contact Person: www.mass.gov/dia Applicant I nformation Please Print Lcsibh' Insurer's Address: Ollicial use only. Do ,tot write in lhis area, to be completed by ciq' or town ouicial. Information and Instructions Massachusctts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this stairte, an ernployee 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 olhcr legal entity, employing employees. However, the owner of a dwellir:g house having nol more than thrce apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or on thc grounds or building appurtenant thereto shall nol bccause of such employ"rnent be dccmcd to be an employcr." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or rcncwal of a license or permit to opcratc 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 entcr into any contract for the perfbrmance ofpublic work until acccptable evidence ofcompliance with the insurancc rcquircnrents of this chaptcr havc becn presented to thc contracting authority.'' .4pplicants Please fill oul 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 employecs 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 thrs affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurancc covcrage. Also be sure to sign and date the aflidavit. The affidavit should be retumed to the city or lown thal the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any queslions regarding the law or ifyou are required to obtain a workers' compensation policy. please call the Department at the number listed bclow. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Plcasc be sure that the affidavit is complele and printed legibly. The Department has providcd a space at the bottom ofthe aflidavit for you to hll out in thc evenl the Office of Invcstigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. [n addition, an applicant that must submit multiple permit/licensc applications in any givcn ycar. nced only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been oflicially stamped or marked by the ciry or town may bc plovided to the applicant as proufthat a vaiid affidavit is orr file for frrtuie 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 venture (i.e. a dog liccnsc or pcrmit to bum lcaves etc.) said person is NOT required to complete this atlidavit. Thc Office of Investigations would likc to thanl you in advancc 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 lnvestigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I -1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia