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Home My WebLink About2025-269Z0Z i z Nnr 'toF, ?h-/Va,./277/ LICENSE FEE $ I50 E4HH-23-tgZq r\* Ot'\'..\RllOt'IH BOARD OF IlE.\l.TH AND SToRAGE OF TOXIC OR HAZARDoUS M.\TERIALS LICENSE APPLICATION CO}IPLETE THIS APPLICA'IION AND RETTIRN IT WITH THE LICENSE FEE BY JUNE 30. 2025 s.t-; $!rtal.L DPLEASE CONIPLETE ALL OUESTIONS NAMEoFBUSTNESS Sria 5r'.ro 5'tc BUSINESSTEL. * Sbv-4tt ^JO5bi_T BUSINESS ADDRESS IN YARMOUTH t3,) ?tpo.:,nr-l 5t-"sf MAII-ING ADDRESS ? A P-'ov z+V ct EMAIL ADDRESS &+5'\o s. co.^ BIJ)I.[&L,D MANAGER/CONTACT PERSON rnnrlq --l a uf<-) TELEPHoNE# 5D7' 3q7. aaSt BEqLIEED OWNER NAME HoME ADDRESS t.b<-rf-TEL.#>t.t. 4-- S d n'-tk TEL. # )a- CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS rAx rD (FEIN oR ssN)BBOUIRED C,4'lz3oz 3{ LICENSES RUN ANNUALLY FROM JULY I TO JTINE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ART RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE RTQLTIRED PRIOR TO REOPENING. Town ol Yarmouth taxes and t5r(.urt be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yesy' no _ n a- Under Chapter 152, 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 Compensalion Atfidavit. If not applicable. please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK.ERS COMP AFFIDAVIT ENCLOSED ALL SAFEry DATA SHEETS ON FILE \,N ,ANY NEW CHEMICALS }TUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT RENEWAL APPLICATION \ APPLICANT'S SIGNATTIRE DATE lzozq tdtc H-t't\rl H MAILING ADDRESS- ; _{v NEW APPLICATION DAIE I /OO/YYYn 0613012025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLOER. IMPORTANT: lf the certificate holde. is an ADDITIONAL INSURED, the policy(ies) musl have ADDITIONAL INSURED provisions or be endorsed lf SUBROGATION lS WAIVED, subject to the terms and conditions of lhe policy, certain policies may require an endorsement. A statement on this certilicatc does not conter .ights to lhe certificale holder in lieu of such endorsement(s). PROOUCER BALDWN KRYSTYN SHERMAN PARTNERS LLC E Rogers and Glay Processing E (508) 398-7980 mail@rogersgray.com 4211 West Boy Scout Blvd Suite 800 Tampa INSURER(S) AFFOROING COVERAGE FL 33607 LM INS CORP 33600 INSURED INSURER B SHIP SHOPS INC II{SURER E CERTIFICATE OF LIABILITY INSURANCE COVERAGES cERT|F|CATE NUMBER: 1131023 REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR INDICATEO. NOTWITHSTANDING ANY REAUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH IHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS THE POLICY PERIOD 5COMTIERCIAI GEN ERAI TIABILITY EACHOCCURRENCE CLATMS,MAOE L l OCCUR N/ I PRooUc's. coMP/oP AGG I3f-]r GENERAL AGGREGA'TE ' & ADV INJURY S L PBEULSIS tE! q!a!!!!9.L 1tT-- f-o* E ,** OTHER: EGAIE LIMIT APPLIES PER EiE"t E.o" L ] aNY AUTo I auros oNLYI HIREDL.l auros oNLY BOOILY INJURY (P6ipels) AL]TOMOAIfE LIAB ILI]Y BOOILY INJURY (Per a(n.nt)-l scHEour.EoI AUTOSf l NoruowNEDi _] Auros oNrY EACH OCCURRENCE AGGREGAIE occrJR CL^lMS-MADE oEo RETENTION! woRxERs cofPENSarK)i AI{D E FLOYERS' LIABLTY ANYPROPRIEIOfiYPARTNEFVEIECIJIIVE OFFICER/MEMBEREXCLUOEO? oEscRlPTloN OF oPERATIONS belo*E L OISEASE, POLICY LIMIT X N/^ N/a WC5315332261025 s 500,000 EL OISE'"SE , EA EMPLO o1t2612025 01t26t2026 E L EACH ACCIOENI s 500,000 s 500.000 oESCRtPnON OE OPEFAnONS / tOCATrOrlS / VEHI9IES (ACORO 101 , Addrdon.l R.m.rL Sch.<lol., m.y b. .tlr.r'.d It n4 .p@ l. r.q!l.d) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in stales other than Massachusetts ifthe insured hires, or has hired those employees outside of N,lassachusetts. This certilicate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date ofthis certificate of insurance). The status of this coverage can be monitored daily by accessing the ProofofCoverage - Coverage Verification Search tool at www.mass.gov/lwdArorkeE-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION MA 02664 SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CATICELLEO BEFORET}iE EXPIRATION DATE THEREOF, iIOTICE WILL BE DELIVERED IN ACCORDANC€ wlTH THE POLICY PROVISIONS. AUIH ORIZEO REPRES ENIATIVE . )-{ rL DaniEl M. C t"e' CPCU. Vicg President - ResidualMarket - WCRlBli^A O 1988.2015 ACORD CORPORATION. All rights resorved. Tho ACORD name and logo are registored marks of ACORDACORD 25 (2016/03) MA 02664 PO BOX 248 SOUTH YARMOUTH L MIT 5 5 S S 5 UTgREILA LAB EICESS UAB Ship Shops lnc 130 Pleasant St. PO Box 246 South Yannouth