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Home My WebLink About2025-260h t'lo I sl, PI-EASE CO}IPLETE ALL OI ESTIO:\IS NAME OF BUSINESS kt BUSINESS TEL BUSINESS ADDRESS IN YARMOUTH 2 ll 9o&a 5h6r PrrVe LICENSE FEE S r50 6HHI.{-L3-{qbs TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATE LICENSE APPLICATIOiT- COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FE BY JUNE 30, 2025 rgEgfE t oFl9tr](o-+ rdo=EffiF3 la,la, om!--{ *o,a,*ooro*r, P0 S.Q( (\owi-t 0)4oq EMAIL ADDRESS 5n fndhl g. arll m BEOIIIBED MANAGER/CONTACT PERSON ndrq Q' $'1va n n ' TELEPHONE #5)t-sqt-qssa BIA.UTBED owNEnNavr J?1 SurM St.r'r prt V, LL{s.* HOME ADDRESS 0 10 S.(4( tl\4"{1 Y^r1 0>GC1 CORPORATION ADDRESS I 1 furp{a nt L4 r'S Ofr^o*1 pr+ 0)-40V t{5-Y18 sfia (tr 3t.r ra. CORPORATION NAME (IF APPLICABLE)-TEL. # \,I A II ING ADDRFSS LICENSES RTIN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY 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 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 Compcnsation Affidavit. lf not applicable, please explain appropriately ifpaid: yes-- no- n/a 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 Cenification of Workers Compensalion insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers REGISTRATION FORM SIGNED AND COMPLETED ,/ CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED I/ Yt N ALL SAFETY DATA SHEETS ONFILE (/ YN ANY NEW CHEMICALS MUST BE PRE.APPROYED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION APPLICANT'S SIGNATURE NEW APPLICATION- ,o116'/7't> .!l,r! rAx rD (FEIN on ssrlR@IS.D 05t01t2025 TMPORTANT: tf the ce.tificate holder is an ADDITIoNAL INSURED, the policy(ies) must be endorsed. lI suB ect to tho terms and conditions of the policy, certain policies may require an endotsement. A statement on this certificate does not confer rights to the cettificate holder in lieu ot such end subj ROGATIONIS WAIVED. s Fu (508) 775-1 135PHoNE (508) 771-1660 €,MAIL AOORESS: INSURE R(S) AFFORDING COVETlAGE 19682rNsuRER a : Hartford Firc lnsurance Company INSURER B INSURER D INSURED SKP,IM, LLC., 731 MAIN STREET LLC, 277 S, SHORE DRIVE LLC DBA SKIPPY'S PIER 1 PO BOX 370 SOUTH YARMOUTH MA 026&I.0370 ,.'-ilr cERTTFTcATE oF LrABrLrry TNSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTI FICATE HOLOER. THIS CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER AUTHORIZED REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER COVERAGES CERTIFICATE NUMBER REVISION NUMBER RT CANCELLA O 1988-2015 ACORO CORPORATION. All rights reserved The ACORD name and logo are registered marls of ACORD IHIS IS TO CERTIFY THAT IHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED INDICATED NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO V\4.IICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFOROEO BY THE POLICIES DESCRIBED HEREIN IS SUEJECT TO ALL THE IONS ANO CONDITIONS OF SUCH POLICIES LIMITS SHOvvli MAY HAVE BEEN REDUCED BY PAID CLAIMS NAMED ABOVE FOR THE POLICY PERIOD TERMS EXCLUS LIMITSLIBRPOLICY NUMBERryPE OF INSURANCE EACH OCCURR€NCE TO RENTED MED EXP {Any one perso.) CLAMS,MADE OCCUR PERSoNAL & Aov TNJURY GENERAL AGGREGATE PRODUCTS . COMP/OP AGG G€N L AGGREGATE LIMIT APPLIES PER LOCPOLICY OTI]ER JECT BIN€O SINGLE LIMIT EOolLY INJURY (Per pe6on) BODILY lNJl-lRY LPer acc de.l AMAGE AUTOMOBILE LIABILITY AL! ol l{Eo AUTOS HIRED AUIOS SCHEOUL€O AUTOS NON,O!!NEO AUIOS EACH OCCURRENCE AGGREGATE OCCUR CLAIMS MAOE UMBRELLA LIAS EXCESS LIAB nererr or $ x PER s1.000.000E L EACHACCIDENT $1.000.000 E L DISEASE, POLICY LIMIT s1 000 000 05t30t2025 05130D026 ANO EM PLOYERS' LIABILITY PROPRIETOR/PARTNESYEXECUTIV€ OFFICEfuMEMBER EXCLUDED'08 WEC AD1A4A DESCNPTIOI,I OF OPEFa tO S / LOCAIIO S / VE'|CLES (ACORD 1or, Additio..l Remr*3 Sch.dul., ,n y b. tlt.chod il more 3p..o is required) Those usual to the lnsured's Operations. SHOULD ANY OF THE ASOVE OESCRIBEO POLICIES BE CANCELLED BEFORE THE EXPIRATION OATE THEREOF, NOTICE WILL BE OELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, duuu,.r d /az6--.*-t AUTHORIZED REPRESENTATIVE 277 South Shore Drive. LLC Surf and Sand Motel Sandra M DiGiovanni PO Box 370 South Yarmouth MA 02664 ACORO 25 (2016/03) PRODT'CER THE OCEANSIOE INSURANCE GROUP 08084400 PO BOX 38 WEST OENNIS MA02670 INSI'RER C I INSURER E: INSURER F l INSF COMMERCIAl GENERA! LIAEILIry E L OISEASE,EA EMPLOYEEl