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Home My WebLink About2025-262025t2026 CO}IPI, PLEASE COMPLETE ALL OLTESTIONS NAMEoFBUSTNESS ttop+ ahry, *aa -BUSINESS ADDRESS IN YARMOUTH LICENSE FEE $ I50 B,HHl,t-2-5-Fil/ \IOT'TH BoARD OT- HEAT-]'H GE OF TOXIC OR HAZARDOUS M.\TERIAI,S \SI].\PPI,I(.,\TIo\ N ,\\D RETUR\ IT \}'ITH THE LI(]f NSE FEE E 30.2025 ,/-" s"sctillitD susrNess rEr-. + 50 3?4- t L, e- 'dl$WilWvoANflfuilE}ilMP; ,rEl-s_€l ,\TI o MAILING ADDRESS IMAIL ADDRESS Y2 andg COVA EEOIJIBED MANAGER./CONTACT PERSON rer-rpHoNs + 5oG - 344- I a3+ d rnSmi{-h B8Q.LII.B.ED OWN ER NAM E e s Lru* Lol'l -110 -8708 HoMEADDRESS I b coRpoRATToNNAME(rFApplrconre, S0ymp rel.+ CORPORATION ADDRESS MAILING ADDRESS C\l TAX ID (FEIN OR SSN)REOUIRED OU-3)lDtq+1 LICENSES RLTN ANNUALLY FROM JTILY I TO JLTNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQI,IIRED FEE(S) BY JLNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOTIR ESTABLISHMENT LNTIL 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 renerval or issuance of your permits. Please check appropnately ifpaid: yes -/ 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 Cenification of Workers 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 C]HE,CK AND WORKERS C]OMP AFFIDAVIT ENCLOSED /F ALL SAFETY DATA SHEETS ONFILE './N ANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION APPLICANT'S SIGNATURE NEW APPLICATION DATE Oh.tt)O. s'ToossU{6o rol'"i^< TOWN OF YARMOUTH BOARD OF 202512026 HANDI,ING AND STORAGE OT' TOXIC OR LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT BY JUNE 30, 2025 NAME OF BUSINESS BUSINESS ADDRESS IN YARM MAILING ADDRI]SS S# Gu.A al LTCENSE FEE $r5o B H H lY23- I I / Z HEALTH IIAZARDOUS MATERIALS WITH THf, LICENSE FEE/*\ 'a-. C'rt"r-l -" 99iLlrrrU BUSTNESS rEL. # Sogiq4- oq1 I EMAIL ADDRESS Sio a? IIEOUIRtrIT MANAGER/(]ONTACT PERSON TELEPHoNE # 50t -30i*' 64?t BgllJJltsuDowNHR NAM e LtI- r et.* lorl -'t1 O -$1 O Z d HOME ADDRITSS CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS MA a Some-TEL. # MAILING ADDRESS TAX ID (FEIN OR SSN) REOUIRBD 04- SototL+q1 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILIry TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQT]IRED APPLICATIONS(S) AND FEE(S) AR-E RECEIVED. A HEARING BEFORE THE BOARD OF HTALTH MAY BE REQLIRED PRIOR TO REOPENINC. Town of Yarmouth taxes and liens must bc paid prior to renewai or issuance ofyour permits. Please check appropriately if paid: yes v/no- tla Under Chapter 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 Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Allidavit. If not applicable, please explain: REGISTRATION FORM SICNED AND COMPLETED CHECK AND WORK-ERS COMP AFFIDAVIT ENCLOSED YNALLSAFETYDATASHEETSONFILE _-:ZYN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTII DEPARTMENT. RENEWAL APPLICATION r'.- NEW APPLICATION APPLICANT'S SICNATURII PLEASE COMPI,ETE ALL OTiESTIONS DArE: Laltsf e{ The Commonwealth of Massachusetts Department of Industrial Accidents Ollic e of I nve stigatio ns Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organi zation Name: The Stop & Shop Supermarket Co LLC Address: 1385 Hancock Street CitylStatelzip'Quincy, MA 02169 Are you an employer? Check the appropriate box: 1.[l I am a employer with i00+ employees (full and/ or part-time).i 2. E I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ! We are a corporation and its officers have exercised their right ofexemption per c. 152, $ I (4), and we have no ernployees. [No workers' comp. insurance required]+ +. ! We are a non-profit organization, staffed by volunteers, with no employees. fNo workers' comp. insurance req.] Buslness Type (required): s. fl Retail 6. ! Restauranttsar/Eating Establ ishment 7. ! Offrce and/or Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing 11.! Health Care l2.E other tAny applicant thal checks box #l must also lill out the seclion below showing their workers' cornpensation policy information. *+Ifthe corporate officers have exempted themselves, but the corporation has other employe€s, a workers' compensation policy is required and such an organization should check box #1. I tm an employer that k providing workerc' compensatioa insurunce for my employees. Below is the policy information. Insurance Company yu.". lndemnity lnsurance Company of North America Insurer,s Address:436 Walnut Street - PO Box 1000 CitylStatelZip Philadelphia, PA 19106 Policy # or Self-ins. 11g. 6 wLR C72604672 Expir u1i6n p,x1s. 1211125 Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veriflrcation. I do hereby certify, under lhe pains and penalties of perjury that the information provided above k true and correcL Si ture:Kn A-D 11120t24 Phone #:617-770-8 8 OfJicial use only. Do not n'rite in this area, to he completed by city or town official. Issuing Authority (check one): lflBoard of Health 2[ Building Department 3^E City/Town Clerk PermiVlicense # 4. ELicensing Board Phone #: City or Town: 5E Selectmen's OIfice 6. Eother Contact Person: f\ Applicant lnformation Please Print Legiblv Phone #: 800-288-8415 www.mass.gov/dia Information and Instructions An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or truslee of an individual, partnership, association or other legal entiry, employing employees. However, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house ofanother who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because ofsuch employment be deemed to be an employer." 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 operate a business or to construct buildings in the commonwcalth for alry applicant who has not produced acceptable evidence of compliance with the insurance 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authonty." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Pafinerships (LLP) with no ernployees other than the members or paflners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the aflidavit. The affidavit 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 Ollicials 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 O{fice of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license 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 affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for furure permits or licenses. A new aflidavit 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 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 Departrnent of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02ll1-1750 Tel. (857) 32t-7406 or I-877-MASSAFE Fax (617) 727-7749 Form Revised ?/2019 WWW.maSS.gOV/dia Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to lhis slatule, an employee is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written."