HomeMy WebLinkAbout2025-26PAIO CA6H
LICENSE FEE $I50 BHHM-23_Bqq
TOWN OF YAR}TOU'I'H BOARD OF HEAI,TH
202512026 HANDLING r\ND S'l OR\Gtl Ol' 'II)XIC OR HAZARD US II4-{'tERIAI,S
LI(]E\SE AP
COMPLETE THIS APPLICATION AND LICENSE FEE
BY JTiNE 30, 2
NAME OF BUSINESS St\v qr,- C\oeJ USINESS TEL, #
gSCAflIiiD
BUSINESS ADDRESS IN YARMO 1 {ZTZ
{MA,-TNG ADDRESS Sa,-,
EMAIL ADI)RESS Srlvq r
RtrOU IRED MANAGER,/CONTACT PERSON
TELEPHoNE# &Ltl
1
U!
Cornccls{ , lc
BEOIJIBEDOIYNER NAME
HOME ADDRESS
(0E)oJ f{_q)rc?lv/c/TEL,#
CORPORATION NAME (IF APPLICABLE)-TEL. #
CORPORATION ADDRESS
MAII-ING ADDRESS
rAx rD (FEIN on ssNlRtrOULItED C)L\ZB?tl 3 I
LICENSES RUN ANNUALLY FROM ruLY I TO JUNE 30. IT IS YOT]R RESPONSIBILIry TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL
RESULT IN CLOSURE OF YOUR HSTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) ANI)
FEE(S) ARE RECEIVED. A HEARING BEI.'ORE THE BOARD OF HEALTH MAY BE REQI]IRED PRIOR
TO REOPENING.
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check
appropriately ifpaid: yes_ no nla-
Under Chapter 152, Sec. 25C, subsection 6, the Town ofYannouth 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 part oftlre renewal or issuance ofyour permits, you must complet€ the enclosed Workers
Competrsation Affidavit. lf not applicable, please explain
Ni]v ./ 0 2025
HEA.LTH DEPT
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVITENCLOSED
ALL SAFETY DATA SHEETS ON FILE
N
ANY NEW CHEMICALS MUST BE PRE.APPRoVED BY THE HEAI,TH DEPARTMENT.
RENEWAI- APPLICATION NEW APPLICATION
_{v
Y
N
APPLICANT'S SIGNATURE Cqr'DATr: L (ZJJ Z
PI,EASE COMPI,ETE ALL OUESTIONS
THIS CERTIFICATE IS ISSUED AS A MATTER OF II,IFOR ANON ONLY ANO CONFERS NO RIGHTS UPON TIIE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGANVELY AITENO, EXTENO OR ALTER TIiE COVERAGE AFFORDEO BY T}IE POLICIES
BELOW, THIS CERTIFICATE OF INSURAXCE OOES NOT CONSTITUTE A CONTRACT BETWE€N THE ISSUING INSURER(S), AUTHORIZED
REPRESE}ITATIVE OR PROOUCER ANO THE CERTIFICATE HOLDER
IiIPORTANT: lf lh. c.rtloc.t hold.r l. .n AOOITIONAL IN8UREO, th. pollcy(lG!) mu3l h.v! AODlfK)}{Al IIiSUREO provlalon! or b. .ndoEod.
It SUBROGAnON E WAIVEO. rubrrct lo the larmr .nd condltionr o( thr pollcy. c.A.ln pollcl.r m.y rlqul]t an .ndo6em.nt. A st l.m.nt on
thl! cqn tical. doc! nol conr.r rlght! to th. c.rdllc.t. hold.r ln lleu or.och .ndoE.iner!t(61,
PeooucEr
BAI.DWN (RYSTYN SHERMAN PARTNERS LLC
421 t Wast Boy Scoul Btvd Suit6 8O0
Tampa _
ll.srrREO
SILVER CLOUD TOI1ING INC
FL 33607
797 RTE 2E
SOUTH YARMOUTH MA 02664
Enn Brilham
ffi"to.6,r, taqoi sse t aot
fffis orrn.brigham@rogersgray.com
l!c, io):
ft5uiai(6) AfFOROTiO COYI^ Ol
HARTFORD UNDERWRITERS INS CO
[ts{rRER a
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30104
txsuiEi D :
IN3UiEi E
N$JEEN F:
CERT]FICATE OF LIAB'LITY !NSURANCE
CERIFTCATE NUMEER; 11 1 1628COVERAGES REVISION NUMAER:
THIS IS TO CERIIFY IHAI IHE POLICIES OF INSURANCE IISIEO AELOW TIAVE BEEN ISSUEO TO IHE INSUREO NAMEO AEOVE FOR IHE POIICY PERIOD
INOICAIEO. NOTWIHSIANoING ANY REOUIREMENI, ]ER r,l OR CONOmON OF AllY CONTRACT OR O]HER DOCUMENI WIH RESPECT TO WHlCri rHlS
CERNFEATE MAY BE ISSUEO OR MAY PERTA'N. THE ITISURANCE AFFORDEO SY THE POLICIES OESCRIBEO HEREIN IS SUBJECT TO ALL THE TERi'S,
EXCLUSIONSAND CONOITIONS OF SUCIi POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS.T-ItsR POTICY I,IUMBERIYPE Of IISI',RAIICE
EACB OCCVRR€NCE-EIAGE IO f,E IED
i ?8EMI5ES tE. o.qrrqgl
lllEl} EXP (An, o.'€ o.rlorl
, PERSOI{A! A AOV llrJuRY
| !El!gq( ^GoREq
-IROOUCTS - COMPIoP AgG
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. conEto^t GErEt t LAaLfi
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GEML AGGFEGAIE L TN APPLES PERi-1"**l lffi i 1,.*
I ofiER
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I aOOtY liurRl lPor oorrr!)t-
r BOOILY $!URY (P.. &rd6nl) ] I
rFRoP€RiYD^uIGE 1.(Pi..(nF0
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SCHEOJLEOATJIOS
NON{Wr,iEO
AIJTOS ONIY
UIIRELLA IIAI
EXCE3S u^g
OEO RETENTION I
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woRtEia col?Et{laliori
AXD EI?LOYERI'UAIUTY
Afi PAOPAIETgfl /PARTT.IER/EXECUTIVE
oFFrcEF./yEI€ER EXCLrl0E Ot{rrld.tay in tlll,
o6scRJpnoN oF oPEFiAroa{s 0.b,.
04i15/2026.6S60U8A396141425 u115t2025 1 100.000
\./iPER toTll.A SIAIUTE I IEn
E-L EACH ACCIDE ,IT
Er osEAsE - EA EMptOyEE. 3, 1@,000
E.L us€asE . PoucY uMrr t 500.000
OE3CEPTIOI{ Oa OPEnAfbxl, LOCAIIONSTVE$CI.E! lAaOaD lol, A.LrEqd i.Dtt. !di.ar5, m, !..nth.<l r mE.c-. L rornd)
Wo.ke,s' Compensslion b€nefits will bo paid to Messachwetts emdoy€ss mly. Pursuant to Endorsemsnt WC 20 03 06 B, no aulhorizati(x is given to
pay daims for benefits to employees in stalss other than Massachus€tts if tie insuGd hires, or has hired thoso emdoye€s odside ot Massachusetts.
This carlificato of insuranc€ shows the policy in forca on th6 dato that this c€rtificate was assi.rod (uoless the expiration date on lhs abovg policy
prBcedes the issu6 date of this oertilicaio of-insurance). Ths stalus of lhis coverage can be tnonitor€d daily by acdssing tho Prool of Cot oraEg -
Covorage Verification Search tool 8t ,JvrMtr.mass.govlwd/wortsrs-compensatlon/jnvastigalioflsJ.
CERNHCATE HOLOER CANCELLA
O 19EE-4115 ACORD CORPORATION. All .i!ht! r.trrved
The ACORD namo .nd logo .r. regi.trred martt of ACORD
SHO{'LD ANY Of TXE ABOYE D€SCRtsEO POUdES BE CAXCELLEO BEFORE
THE ETPNATPI{ OATE T}IEREOF. !'OTICE IITLL SE OEUVEREO IIt
ACCOROAI,ICE IYITH THE POUCY PROVISIONS.
Daniel M. C.orlby, CPCU, v'rce Pr6ident- Residual Mafiet - WCRIBMA
AUTFORqEO REPRSS€XTA'IVE
MA 02664South Yarmouth
Evldsnc€ of lnsurance
797 Routs 28
ACORD 25 (2016103)
,-r -ACORD.
0/t25t2025
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AUTOIO8|LE IIAdLITI
I lowreo IL , N.[osoNLY Ir{tREc
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OCCUR
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EACH @CURREI{CE
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T h a C om m o n wea lth of ful as sa ch u s etts
D e purtm e n t of I n du strial,4 cc idents
Offr <' e of I n ve s ti g at i o n s
LaIa_vette Ciq' Center
2 Avenue de Lafayette, Boston, .llA 02 I I I - 1750
r.'n'w.mass.got'/dia
Workers' Compensation lnsurance Affidavit: General Businesses
Applicant lnformation Plcase Print Legiblv
(-.'Lf v\(,T<-\Business/Organization Name :
nddress: 'X1-l ?f '/ t't
Are vou rn employer? Check the appropriete box:
I . [l I am a e mployer with S( cmployees ( firll and'
or pan-time).*
2. E I am a sole proprictor or partncrship and harc nrr
employces working for me in any capacitl.
[No workers' comp. insurance requircd]
f.! we are I corporation and its officcrs havc excrciscd
thcir right ofexcmption per c. 152, .s I(4). and wc havc
no employees. [No workers' comp. insurancc required]'
l. I We are a non-profit organization. stalTcd by voluntccrs.
with no employecs. INo workeni' comp. insurancc rcq.]
Phone d 1O<< 3lLlLl lLl ICity/State/Zip:
Business Type (requlred):
5. !Retait
6. I RestauranlrBar/Eating Establishment
7. E Ofiice andror Sales (incl. real esate, auto, etc.)
E. I Non-prolit
g. E Entertainmcnt
10.I Manufacturing
I l.[ Heallh Carc
I: R orher
'Anyapplicanllhalchcckrborrlmultalro[illoulthcscctronbckrsrho$rngrhcirr!orlcr\'conrpcnsitlionloli(vioformrliun.
" lf thc corporarc o0iccrs havc cxcmpted thcorselvc\. bur lhc.orpor.tr()n har oth.r emplo!Nr. a \aortcni ronrpcn-iation poh.v is requircd and srrch an
organr/atron should.hcct bor, L
I om an employer that is providing worket' comp.nsoli.tn insurance for my employecs. Below is the ?olicf inlormation
lnsurance Company Name:r\{ n, .,*r-S
Insurer's Address
(tf
City/S131s721,
L LtZ Lxpiration Date ql,slzbPolicy # or Sclfl.ins. Lic. I
I do hereby ccrtif1.,
sicnatire: lU
under lhe pains and penolties ofprrjnq'that thc inf.rrr orlilrj (a,vt(tion protidcd abor'" is true snd corred.
Du ll (
Phone #: <( , S :7{/q q lq
Otlicial use only. Do not write in this or.'o, to bt! (o,t p! ed b)'cii. or l.ttn oJfic.iul.
Pernlit/Liccnse f
Contact Pcrson:Phonc #:
-1^E Ci[*/Town Cle rk {. D l,icensing Board
lssuinB Authoritv (check one):
I fiBoard of Health 2.! Building Deparrmrnr5f] Selecrmcn's omce 6. EOthe r
\l\r1v rnlss gov dla
Atlsch . cop) of the workers' compensalion policv declaralion pege (showing lhr policy numbcr end erpirrtior date).
Failure to sccurc coverage as requircd undc'r rt 25A ofN'l(i[, c. t52 can lcad to the inrposition ofcrinrinal penaltics t,fa fine up
to S1,500.00 and/or one-year imprisonmcnt, as well as civil pcnalties in the tirrm of a STOP WORK ORDER and a line of up to
$250.00 a day against the violator. Be adr ised that a copy ol this statemenl mav be lonvarded to thc Oflice ol Investigations ol'
thc DIA for insurance covcragc verificatiorr.
Citr or Town:
.s The Commonwealth of Massachusefts
Department of Industrial Accidents
Olftce of I nvestigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance AIIidavit: General Businesses
Please Print Lesibly
Print Form
Applicant Information
Business/Organization Name:Sr lu<r- c,\ori<-{
Address: -tsia AT ZV
City/State/Zip:CJ\-l t
+Any applicanl that check box #l must also fill oul the section below showing thei r workers' compensation policy information
**lfthe corpoEte oflicers have exempted themselves, but lhe corpomtion has other employees, a worters compensation policy is requircd and such an
orgalization should check box # I .
Are you au employer? Check the qppropriate box:
l.S t a- a e*ployer *irh tr( ) employees (tull andi
or part-time).*
2. ! I am a sote proprietor or partnership and have no
employees working for me in any capacity.
[No worken' comp. insurance required]
3. E We are a corporation and its officers have exercised
their right ofexemption per c. 152, $l(4),andwehave
no employees. [No worken' comp. insurance required]+
4. ! We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Restaurant/Bar/Eating Establishment
Office and/or Sales (incl. real estate, auto, etc.)
8. I Non-profit
9. ! Entertainment
10.! Manufacturing
I l.! Health Care
\V)
Business Type (required)
5. I Retail
6.
7.
tz.Ebtner
I tm an employer lhat k p
Insurance Company Name
sstiott e lor my Below is the policy informarton.r
City lslarelzip
Policy # or Self-ins . Lic. 4 Expiration Date:-
Attach a copy ofthe workers' compensrtion policy declaration prge (showing the policy number rnd erpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to 5250.00 a day against the yiolator. Be advised that a copy of this staternent may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided sbove is true and correcl
\\UY-rt(z& eSture:Date:
Phone #:wk3 qqq/ull
ollicial use only. Do not wyite in this area, to be complered by city or town official
Issuing Authority (circl€ one):
l. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Oflice
6. Other
Phone #:Contact Person:
Permit/License #
www.mass.govldia
Phone #:
Insurcr's Address:-
")
City or Torrn: _
Information and Instructions
An employer rs defired as "an individual, partnership, association, corporation or other legal entity, or any two or more
ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the
receiver or trustee ofan individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartsnents and who resides therein, or the occupant ofthe
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appunenant thereto shall not because of such emplolrnent be deemed to be an employer."
MGL chapter 152, $25C(6) also states that "every st&te or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings ir the commonw€alth for any
applicant who has not produced acceptable evidence of compliatrce with the insurrnce 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 performance ofpublic work until acceptable evidence ofcompliance with the insurance
requirements ofthis chapter have been presented lo the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to yow 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 employees other than the members
or partn€rs, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is rcquired. Be advised that this alfidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the aflidavit. The alfidavit 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 below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town O[Iicials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Offrce of Investigations 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 permit/license applications in any given year, need only submit one aflidavit indicating current
policy information (ifnecessary). A copy ofthe aflidavit that has been oflicially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affrdavit is on file for future 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 venhre (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations 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
Oflice of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-7274900 ext 406 or I-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Massachusetts General Laws chapter 152 requtes all employers to provide workers' compensation for their employees.
Punuant to this statute, an employee is defined as "...every person in the sewice of another under any contract ofhire,
express or implied, oral or written."
Form Revised 7,2010