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Home My WebLink About2025-26: :_ --=-- -:= TOW 2sl2.g8ftrtllPllq{G (ole,ltEtsEHts ^ 7 [h-No.{&oflo?6tlHt4-23-t 779 Gs*nmo LICENSE FEE S I50 D STOR{GE OF TOXIC OR HAZ.{RDOUS M.\TERIALS LICEN.SE APPLICATION LICATION AND RXTLTRN IT WITH THE LICENSE FEE B\'.tt'NE.10.2025 PLEASE CONIPLE ALL OUESTIO}ISa\ NAME OF BUSINESS BUSINESS ADDRESS IN YARMOUT MAILING ADDRESS cu, EMAIL ADDRESS REOT] I Rf D MANAGER/CONTA(]T PERSON TELEPHONE #5(K-+?t-+eqo o . BUSINESS TEL- # r) u ra a N ru-.* 6la'?6'1Zoo N Ir et.* \la-k{4zq flu ,d RFOT IREI) OWNER NAME MAILING ADDRESS S*nr e At *l-.,xe n r HOME ADDRESS CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS ca/I lP ea 8.7?z LICENSES RUN ANNUALLY FROM JULY 1 TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JL]NE 30, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED, A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yesy' no_ n a _ Under Chaptff 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 Cenification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits. you must comptete the enclosed Workers Compensation Affidavit. II' not licablc, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE NY YNANY NEW CHEMICALS MUST BE PR-E-APPROVED BY THE Hf,ALTH DEPARTMENT. RENE*AL oara,ao,o,u '/ NEw A'.LICATI.N APPLICANT'S SIGNATURE /7 DATE OF YARIIIOUTH BOARD OF HEAL'I'H i TAx ID (FEIN oR SSN) REOUIRED nslxfops- The Commonwealth of Massachusetts Department of I n d u strial A ccide nts Olli c e of I nve sti g atio n s Lofayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses I-i Aoolicant Information Please Print Lesiblv 1{o LBusiness/Organization Name: Address:0 City/State/Zip:llSao 8lo'?,f {-lzoo 5 6 Business T.'-pe (required) Retail RestauranLrBar/Eating Establishment Z. ! Office and/or Sales (incl. real estate, auto, etc.) 8. I Non-profit 9. ! Entertainment 10.! Manufacturing I L! Health Care t2 ! other +l aru'1es".Qt *Any applicaot that checks box #l must also fill out lhe seclion below showing their workers' conrpensalion policy information. *+lfthe corpomte officcrs have exempted themselves, but lhe corporation has olher employees. a workers' compensation policy is required and such an organization should check box #1. Are you an employer? Check the appropriate box: t.Vtama employer *6 A4o ,mployees lfull and 2 3 4 or part-time).* I am a sole proprietor or partnership and have no employees working for mc in any capacity. [n-o workers' comp. insurance required] We are a corporation and its officers have exerciscd their right of exemption per c. 152. Q I (4), and we havc no employees. [No workers' comp. insurance required]** Wc are a non-profit or8anization, staffcd by voluntcers, with no employees. [No workers' comp. insurance req.] I am an employet tha, is p Insurance Company Name rot'l workers' co insurance for my employee's. Bektw is the policy inform ion. tn f9 t\g.tra Insurer's Address CitylState/Zip ( Policy # or Self-ins. Lic. #Expiration Date Attach a cop!' of the workers' compensation policy declaration page (showing the policy number and expiration datc). Failure to secure coverage as required under $ 25A of MGL c. 152 can lead Io the imposition of criminal penalties ofa hnc 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 of this statement may be flor*'arded to the Office of Investigations of the DIA for insurance coverage verification. i) I do hereby certifi,, under the ptins tnd penalties of perjury thu the informotion provided tbove is true and corect, Si ture Date 5- Phone#: Ala' 1z/f - Q/-oO v) Oflicial use onll', Do trot write in this sres, to be completed by city or town official. Phonc #: 3.E Ciry/Town Clerk 4.ELicensing Board City or Town: lssuing Authority (check one): lflBoard of Health 2.! Building Department5[ Selectmen's Office 6. EOther Contact Person: www.mass.gov/dia t t Phone #: tr Permit/License # Information and lnstructions Massachusetts General Laws chaptcr 152 requires all cmployers to provide workers' compensation for their employees Pursuant to this statute, al employee is d,efined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written." At employer is defined as "an individual. partnership. association, corporation or other legal entity, or any two or more ofthe foregoing engaged rn ajoint enterprise, and including the legal representatives ofa deceased employer, or the receiver or trustee ofan individual, partnership. association or othcr legal cntity, employing employees. However. the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house olanother who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtcnant thcrelo shall not because of such employment be deemed to be an employcr." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operatc a business or to conslruct 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 "Neilher the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work unlil acccptable cvidcnce ofcompliancc with the insurance rcquirements of this chapter havc becn prescntcd tc thc conttjrcting authority " Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, il 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 affidavil may be submitted to the Department of lndustrial Accidents for confirmation of insurancc covcrage. Also be sure to sign and date the affidavit, The aflidavit should be retumed 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 bclow. Self-insured companics should cnter their self-insurance license number on thc appropriate line. City or Town Officials Please be surc thal the affidavit is completc and printcd legibly. Thc Department has provided a space at lhc bottom ofthe affidavit for you to fill out in the evcnt the Officc 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. In addition, an applicant that must submit multiple pcrmit/license applications in any givcn ycar, need only submit onc affidavit indicating current policy information (if necessary). A copy of thc affrdavit that has been olficially stamped or marked by thc city or town may be provided to tlre applicant as proofthet a valid affidslit is on file for firture permits or licenses. A nerv :rffidavit 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 license or permit to bum leaves ctc.) said person is NOT required to complete this affidavit. The Office of lnvestigations would like 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 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02lll-1750 Tel. (857) 321-'7406 or l-877-MASSAFE Fax (617)'727-7'749 Form Revised 7/20t9 WWW.maSS'gOV/dia '.HEDULE.F.PERA..NS tr This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: TWN Clry FIRE INSURANCE COMPANY Company Code: 7 Policy Number: 76 WE BR3HS8 Schedule Number: 01-20-06 Effective Oatet 04101125 Effective hour is the same as stated on the lnformation Page of the policy Named lnsured and Location Address of operations covered by this schedule: SID HARVEY INOUSTRIES INC SCST AUBURN MA 01501 NAICS: 423730 FEIN: 11-2233773 SIC: 5075 NO. OF EMPL: 27 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subjectto verification and change by audi!. Premium Basis Total Estimated Annual Remuneration Classifications Code Number and Description Rates Per $100 of Remuneration Estimated Annual Premium 8010 STORE: HARDWARE 8810 CLERICAL OFFICE EMPLOYEES NOC 8742 SALESPERSONS, COLLECTORS OR MESSENGERS - OUTSIDE 7380 CHAUFFEURS, DRIVERS & THEIR HELPERS - NOC. COMMERCIAL Countersigned by Form WC 99 00 05 (1) Printed in U.S.A Process Date: 03/27l25 1,255,844.00 371,144.00 5'19,459.00 371 .144.00 0.940000 0.040000 0.070000 4.960000 'l'1,805 18,409 364 Authorized Representative Policy Expiration Date: 04/01/26 148 This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: TWN CITY FIRE INSURANCE COMPANY Company Code: 7 Policy Number: 76 WE BR3HS8 Schedule Number: 01-20-06 Effective Oatet 04101125 Effective hour is the same as stated on the lnformation Page of the policy Named lnsured and Location Address of operations covered by this schedule: SID HARVEY INDUSTRIES INC ECST AUBURN MA 01501 NA.ICS: 423730 FEIN: 11-2233773 SIC: 5075 NO. OF EMPL:27 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subiect to verification and change by audit. Premium Basis Total Estimated Annual Remuneration Classifications Code Number and Oescription Rates Per $100 of Remuneration Estimated Annual Premium Total State Summary Total Class Premlum Waiver of Subrogation Emp liab increased limits Experience modifier 91 062426 1 Total Estimated Annual Standard Premium Premium discount Expense constant Terrorism Risk lnsurance Program Reauthorization Act Disclosure Endorsement MA DIA Private/Public Assessment (CBAI 62) Surcharge Total Estimated Annual Premium Countersigned by Form WC 99 00 05 Process Date: 03/27125 0.020000 0.020000 1.430000 0.061000 0.030000 4.680000 30,726 615 615 13,741 45,697 -2,788 338 755 2,056 46,058 Authorized Represerrtative SCHEDULE OF OPERATIONS 2,517,591 .00 (1) Printed in U.S.A. Policy Expiration Oate: O4tO1126