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Home My WebLink About2025-26LICENSE FEE $ I50 TOWN OF YARMOUTH BOARD OF'HEALTH 2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE L BY JUNE 30, 2025 sdlutli NAME OF BUSINES BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS EMAIL ADDRESS BI.OUIBED MANAGEPJCONTACT PERSON 'bA 2z-t1a+ lBEGeruao )UN ) ?0?5ht BUSINESS TEL. # TEL.# Itr!'IttrD rtr.J B.UQU.B.ED OWNER NAME CORPORATION NAME (IF APPLICAB CORfORATION ADDRESS MAILING ADDRESS TELEPHONE # TAX ID (FEIN OR SSN) -l I - t'7 tTtr-1se-?r06 LICENSES RIIN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILIry TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED TEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT T-INTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING, Town of Yarrnoulh taxes and,[#ns nrust be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yes_f 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 Compensation Affi davit. If not applicabl e, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE 6-N ANY NEW CHEMICALS M RENEWAL APPLICATION YN APPROVED BY THE HEALTH DEPARTMENl"US'I' BE P APPLICANT'S SIGNATURE NEW APPI-IC ION DATE 4 .lat PLEASE COMPLETE ALL OUESTIONS HOME ADDRESS The Commonwealth of Massachusetts D eport m e n t o f I n tl u strio I Acci d ents Oflice of Investigations Lofayette City Center 2 Avenue de Lafayette, Boston, MA 02lIl-1750 wlru.mass.gov/dio Workers' Compensation Insurance Affidavit: General Businesses P Aoolicant Informati on PIeasc Print Lesiblv Business/Organization Nam Addrcss: CitylStatelZi hone #: I musl also fill oul the section below showing their wotkcrs' compcnsalion policy infonnalion. xempled lhemselves, but th€ corporation has other employecs, a workers' compansation policy is required and such an *Any applicanl lhat ch€cks box f*rlfthe corporate officers hove el olganization should chcck trox #l Are yoSr{n employer? Check the alpropriate box: t.W I am a ernployer wift { 5 e mployees (tull andi or paft-lime).* Z. E I am a solc proprietor or partnership and have no employees working for me in any capacity. _ [No wolkets' comp. insur.ance requiredl 3. Ll We are a corporation and its officers have exercised their right of exemption per c. 152, gl(4), and we have no employees. [No workers' comp. insurance required]* 4. f| We are a non-profil organization, staffed by voluntecrs, with no employees. [No workers'comp. insurance req.] Retail Restaur anYBar/Eating Establishment Z. ! Office and/or Sales (incl. real estate, auto, elc.) 8. ! Non-profit 9. E Entertainmenl 10.! Manufacturing Carellf] Business Type (required) 5 6 I oru on employer th is pro g workers sation for ny employees. Below is the policy hrlorr ation. lnsurance Company Name Insurer's Address CiylSratelZip Policy # or Self-ins. Lic. # Attach a copy of the rvor Failure to secure coverage Expiration Date kers'compensation policy declaration page (shorving ahe policy numb as requircd undcr g 25A of MGL c. 152 can lead to the irnposition ofcrinrinal 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 $250.00 a day against the violator. Be advised that a copy ofthis statement may be for.warded to the Office of Investigations of d expiration d.te). penaltics ofa fine up the DIA for insurarrce covcrage vcri tron I do hereby ture P of peiuty that the htfurmation provided a is lt'ue utd cot,t ect. D # Oflicinl use onlS,. Do ,tot terite in this trea, to be corrrpleted bJr city ot towt, olrtciil. lssuing Authorily (check one): lf]Board of Health 2.E Building 5[ Selectmen's Office 6. Eoth€r Contact Person: Department 3^flCfty/TolvnClerk 4.flLicensingBoard Phone #: Permit/License # $ r'rv.mass.gov/dia frc t2. Citv or Town: --lA'toRD'MACFENE.{I1 CERTIFICATE OF LIABILITY INSURANCE 612112024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERNFEATE HOLOER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEI{D OR ALTER THE COVERAGE AFFORDEO BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PROOUCER, ANO THE CERTIFICATE HOLDER. IMPORTANT: lf ths certllicato holder is an AOOITIONAL INSUREO, tho policy(les) must hav€ ADDITIONAL INSUREO provlslons or be endo6ed. lf SUBROGATION lS WAIVED, subrect to the terms and condalions oflhe policy, certain policios may roquiro an endoBement. A statGment on this corlificate does not conler righls to tho certmcab holdor in llou of 3uch ondorsomont(s). AssuredPadne.s New England, loc. 10 Commerce Way #3Raynham, MA 02757 33758 22314 '16370 12936 35408nINSLJRER 8 um lnsumnce Com 508 506-5533 rs.comDe crxsuRERD:RSUI lndemn crance Co Denise Oeleo 506-5533 IXSURER A: HOUSION AIMMacFarlane En.rgy lnc. d/b/a South Shoro Hoating t Cooling 95 Bridgo Stroet Oedham, MA 02026 lnsurance Company THIS IS TO CERT1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDIT]ON OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN. THE INSURANCE AFFORDED AY THE POLICIES OESCRIBED HEREIN IS SUEJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE EEEN REDUCEO AY PAID CLAIMS, E4Eq El41&re!e-Qeq!'l 711t2024 PEFSONAT A ADV INJURY GENERAf A@REGATE 2,000,000 s t s 3 5 0 OA'TAGE TO RENTEO EACH NCE 1,000,000 100,000 '1,000,000 2,000,000 COIIMERCIAL GENERAL LIAB|LTTY CLAII/TSMAD€ [ occua ECAPl -HS-GL-000130{3 A l17 12023 LOC J GEML AG6RE6A-rE L|MTI[-.."f 69I I orr.", COMBINED SINGTE LIMfT s ECAPl ICMACA{00130{4 111t2021 7t112025 xi X mry auro x NON.OWNEO B ruroMogr-: uaaLm SCHEOULEDAWCISl ] ALnos oNLY HIREDAUTOS ONTY MCSgO Filinq EACH OCCURRENCE 4,000,000 S -HS-CX.o00 t30{3 lecmr 7t1t2024 7l'12025 4,000,000cLAtMS-MAO€ DED RETENTION 3 A x 0x wMz{00{007893-2023A 1,000,0007t1120247t112025 s E,L. OISEASE, POLICY LIMIT $ EL OISEAS€ . EA EMPLOYE DENT 1,000,000 1,000,000 woRt(ERli corPE s tt(,ll| AIIO EXPLOYERS' LIAa|LJTY ANY PROPRIETOR/PARTNER/EXECUNVE OFFICER,,MEMBER EXCIUOED? oEscRtPTtoN oF oPERATToNS b€r* c 7t1l?021 711t2021 711t2025 71112025 2nd layr l5M xof $4M 3rd layr $5M xof $5M 5,000,000 5,000,000 D E Excess Liability Exce83 Liability NHAt03323 ECAP8EXSX0000t'l-02 DESCRPnON OF OPERAnOIS / LOCAnO S / VE|iICLES {ACOFO ',r01, Addrdo l R.orra Scn dut , r y tr.neh.d r hd .9s l...qolnd) Insurance covorago ls limitod totho torm!,condllion3, .xcluslon!, olh.r limll.tion! and endoBem€nb.Nothlng cont.ined ln tho cordfctto of inrurancs 3hall be deemod to hayo alterod, waivGd, or oxlend,ad thg coverage ptovld€d by the pollcy provialons. SHOULD AiIY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOT{ DATE THEREOF, NOTICE WLL BE DELIVERED IX ACCOROANCE W]TH THE POLICY PROVISIONS. r- I ATJTHORIZED REPRESENIANVE Town of Yarmouth 1145 Route 28 South Yarmouth, lliA 02664-1492 O 1988-2015 ACORD CORPORATION. All rights r€served The ACORD name and logo arc roglstored marks of ACORD ACORD 2s (2016/03) x x UXBREI-]. LIAB EXCESS LIAB x oTB- N