HomeMy WebLinkAbout2025-26cti.No.tr28
LTCENSE FEE sr50 BHHt4 -23-lg&S-
2023t2026
R}'IOUTH BOARD OF HE-ALTH
RAGE OF TOXIC OR HAZAR.DOUS MATERIALS
ENSE APPLICATIONLC
COMPLETE THIS APPLICATION AND RXTURN IT WITH THE LICENSE FEE
BY JUN-E 30, 2025 ,.__\
PLEASE CONIPLETE ,4.LL OLESTIONS
NAME OF BUSINESS a, f.o,.rb<,. ",'t {\"Occe n
BUSINESS ADDRESS IN YARMO
MAILING ADDRESS
BUSINESSTEL.# 5ob nql- 8C3o
SrSgrtutrD
sh
3o. Yarmouth, MA 02664
JUL 0 7 ?025
tsGG
S
HEAT fl/oF \'
,!-Fr-rsU 1j
EMAIL ADDRESS (')usloLd (a hol rmiL, <,o rr1
REOUIRF I) MANAGER/CONTACT PERSON
TELEpHSNE# 506 51q- 8190
EI.QIIBED OWNER NAME )u
T"sltn,o\
1..TEL.# 5oE 39!r- 89 3o
HoMEADDRESS \1a 5.5\o,.. D".
CORPORATION NAME (IF APPLICABLE)
CORPORATIONADDRESS 5a'.t€
5,., C <oa\2<, LLC TEL.# 5% legij 130
A> ADqvf
TAX ID (FEIN ON SSNI REOI.]IRED 93- to5o56 t
LICENSES RLTN ANNUALLY FROM JULY I TO JTNE 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) AITE RECEIVED, A HEARING BEFORE THE BOARD OF TIEALTH MAY BE REQUIRED PRIOR
TO REOPENING.
Town of Yarmoulh taxes and liens musl be paid prior to renewal or issuance ofyour permits. PIease check
appropriately ifpaid: yes_.( no_ nla-
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 pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers
Compensation Affi davit. lf not arrplicablc olease exolain:
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED V
N
YN
ANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT.
RENEWAL APPLICATION X
APPLICANT'S SI(iNATI IRF,
NEW APPLICATI N
MAILING ADDRESS s A ..{ 6 +S 4 Bo\ 6
DATE: OIU!AT---1_-
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers lnsurance Company
54 Third Avenue, Burlington, Itlassachusetts 01803-0970
(800) 876-2765 Ncct No 4oese
POLICY NO
PRIOR NO.
wcc-500-50'1 7560-2025A
wcc-500-5017560-2024A
ITEM
1 The lnsured: Surlcomber LLC
DBA:
Mailing address: 107 South Shore Drive
South Yarmouth, MA 02664
FEIN: 'rt"0581
Legal Entity Type: Limited Liabilily Company
Other workplaces not shown above:
The policy period is from 01/01/2025 to 0110112026 12:01 a.m. standard time at the insured's mailing address2
3 A. Workers Compensation lnsurance: Part One ol the policy applies to the Workers Compsnsation Law ol the
states listed here: MA
B. Employers' Liability lnsurance: Part Two ol the policy applies to work in each state listed in item 3.4.
C. Other States lnsurance: Coverags Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schsdules: SEE SCHEDULE
4. The oremium tor this oolicy will be determined by our Manuals ol Rules, Classilications, Bales and Raling Plans
All irilormation requirid beiow is subiect to veriliiEtion and change by audit.
500,000 each accident
500,000 policy limit
500,000 each employee
Classilicalions Premium Basis Rates
Code
No.
Estimated
Tolal Annual
Remun€ration
Per $100ot
Remuneration
Estimated
Annual
Premium
INTER
Minimum Premium $267
ilill illl
GOV
CLASS
CLASS CODE SCHEDU
Stale Assessments/Surcharges
$2,772.00 x 4.6800'/.
$3,238
$843
$130
wc 00 00 01 A (7-11)
lnclud.! copyrhhLd mat.rid olth. flttlottl Councll on Cotlpcn..llon lniu]'nc''
uled rvllh lt3 parmlr.ioi.
HUB lnternational New England LLC
PO Box 696
Wilmington, MA 01887
GOV
STATE
9052
The limils of liability under Part Two are: Bodily lniury by Accident $
Bodily lnjury by Disease $
Bodily lnjury by Disease $
illll
Service Office:
54 Third Avenue
Burlington MA 01803
Total Estimated Annual Prsmium
Deposit Premium
This policy, including all endorsemsnts, is hereby countersigned bv l->-:=7"'Z- fl!a3024
AutlDd2ed60nalure Date