HomeMy WebLinkAbout2025-26Ch.No. 1ozltt3
TOWN OF YARMOUTH BOARD OF HEALTH
202sl2026HANDLrNGANDSroRAr.f jllli#;,3lnor?€1t]:MATERTALS
COMPLETE THIS APPLICATION AND RETURN IT WITH THE DTII@{AE FEE
BY JUNE 30, 2025 ' ,') /tt,,
LICENSE FEE SI50 8HHr4-L3,-t9!0
HEALry
-frPLEASE CONIPLETE ALL QUESTIONS
NAME OI.' BUSINESS
BI.JSINESS ADDRESS IN YARMOUT
MAILING ADDRESS aq L'i
EMAIL ADDRESS
BUSINESS
ALh
TEL. 4
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nca.
(::;:lBEIIIIIBED MANAGE R/CONTACT PERSON
TELEPHONE #{-76
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novr eoon-ess l-.
NAM
CORPORATION NAME (IF APPLICABLE
CORPORATION ADDRESS l)
rcr*F1?40A JA4
oavT(TEL. #Y1 )2
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MAILING ADDRES -o
TAX ID (FEIN OR SSN)REOUIRED o4 -afi o36b-
LICENSES RLTN ANNUALLY FROM JULY I TO JLINE 30. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JTNE 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.
Torvn of Yarmouth taxes and lpns must be paid prior to renewal or issuance ofyour permits. Please check
appropriatell ifpaid: yes-121 no n a-
Under Chapter I 52, 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 Workcrs Compensation
insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers
Compensation Affidavit. lf not applicable, please explain:
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFETY DATA SHEETS ONFILE
N
N
AT.Y NEW CHEMICALS NIIiST BE PRE-APPROVED BY THE HEALTH DEPARTME:\,IT.
RENEWAL APPLICATION
?0
t/2
Y
APPLICANT'S SIGNATURE DATE
^li
NEW APPLICATION
sNow&Jo{1
A,CORD CERTIFICATE OF LIABILITY INSURANCE
:HIS CERTIFICATE IS ISSUEO AS A I{ATTER OF INFORUATION ONLY AND CONFERS NO RIGHTS UPOI{THE CERfIFICATE HOLOER. THIS
CERTIFICATE OOES NOT AFFIRIIATIVELY OR NEGATTVELY A END,EXTEND OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES
BELOW. THIS CERNF|CATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORlzED
REPRESENTATIVE OR PRODU CER, ANO THE CERTIFICATE HOLOER
TE HU NU R:
THIS IS TO
INDICATED
CERTIFY THAT THE POLICIES OF
NOTWITHSTANDING ANY REOUIREME
INSURANCE LISTED BELOW HAVE BEEN
NT, TERM OR CONDITION OF ANY
IsSUED To THE INSUREO NAlt'iED ABoVE
CONTRACT OR OTHER DOCUMENT WITH
FOR THE POLICY PERIOD
RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFOROEO gY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITION S OF SUCH POLICIES, LIMITS SXOWH UAV HIVE EEEN REDUCEO BY PAIO CLAIMS,
uxllsSUERPOLICY XI.IIBER
O 1988-2015 AcoRD coRPoRATlON. All right!
F
SHOULD A{Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
iiii-lxirnliron DATE THEREoF, tlorlcE l!,lLL BE oELIVERED ltl
lCEoaolnc: wmt nE PoucY PRovlslolts
AUTHORIZEO REPRESEI{IATIVE
DAIE {X[/DD/YYYY)
611712025
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ndorsedonstsUREDsONALNADDITIprovllesstmuthepollcy(h tdNTtftheIMPO enlstatemorseJEnaendmalnciesquayofdltionsthepolpollcyandtennstothetONTIsBSUROGAwAtvEo,ubrect endocuIihsuofoldorhnthocalortifitonotIrtlflcatedooth$l[If"r Tara Sousa
lrlrxtss. tarasousa@worldinsurance com
IIiSURElIlI AFFORDIIiG CO]G!6GE
tNsuRER^ |Seloctive ![suElncs Col[pany of Amqrica
rxsuRER B: Selective lEurance Co ollouth Carolile
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World lnaur.nco A!.oci.t t, LLC
670 Plo!.nt St.
BrocKon, ,rA 02301
snow & Jono!. lnc.
PO Box 157
E5 Accord Park Dtlve
Accord, MA 02018
12572
19259
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ACORD 25 (2016/03)
Tho ACORD namo and logo ars registorrd ma7*s ol ACORD
reserved.
Town of Yattllouth
Y.rmoulh, t{A
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