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Home My WebLink About2025-26\0\q\ LICENSE FEE S I50 .l-lN-a=- I 3 TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOX-IC OR HAZARDOUS MATERIALS LICENSE APPLICATIoN REcrrrro^ COMPLETE THIS APPLICATION AND RETURN IT WITH THE-IICEFSf, FEE BY .IIJNE 30. 2025 ,i.lll .., ,) 0,,\ PLE.{SE COIITPLETE ALL OUESTIO}IS NAME OF BUSINESS BU BUSINESS ADDRESS IN YARMOUTH MATLTNGADDRESS 9^nY- ob?\u cL(n c\L lsrrnrte Go+QrrvUd ,^"*lf;" W{,ms-+s+,4 t b erSlrtlatr lEMAIL ADDRESS BEqLIBED MANAGER/CONTACT PERSON J onn !htc.4k TELEPHONE #sw-zal- l1Lz'1 BE.qL]IB,EDOWNER NAME Jonn{c,*cza*_TEL.#g)84a1-ru81 HOME ADDRESS arslonE tu\, tts CORPORATION NAME (IF APPLICABLE)-TEL. # TAx ID (FEIN OR SSN) RT]OT]IRF,D o+-z t844L* ( CORPORATION ADDRESS .s -drtiens must be paid prior lo renewal or issuance of your permits. Please check y.rfl 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 pirmit 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 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBIL ITY 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 REOPENINC Town of Yarmouth tax appropriately if paid: Compensation Affidavit . If not applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE / / Y APPLICANT'S SIGNATURE DATE t?\3 | 6 I MAILING ADDRESS ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. ./ RENEWAL EPPLIT'AIION J/ NFW APPLICATION- F N The Commonwealth of Massachuseus D epartm ent of I n du strial Acc i den ts Oflic e of I n ve s ti g ati o n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02III-1750 www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses Business/Organ eddress: tbb Qb)-$ ization Name: f evmtle 0 o?c t Cod Tnc- City/State/Zip:S arwroul4r MA 02L6frnon"o.5a8-3q8- 48+4 Business Type (rcquired) 5 6 Retail RestauranL/Bar/Eating Establishment z. ! OfIIce and/or Sales (incl. real estate, auto, etc.) 8. 9. l0 Non-profit Enterlainment Manufacturing I I .f] Hcalth Care t:.y'othcr Szyvtca - *Any applicaot that checks box # I must also fill out the section below showi[g their workers' compensation policy information. *ilf the corporate officers have exempted themselves. but lhe corporation has other employees. a workers' compensation policy is required and such an organization should check box #l- I am a sole proprietor or partnership and have no employecs working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4), and we have no employees. [No workers' comp. insurance required]+ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 3.E ') ,1 ou an employer? Check the appropriate box: employees (full and/ Are v t.d I am a employer with or part-time). + I am an employer that is providing workers' compensation insurance lor my employees. Below is the policy information. Insurance Company Nu,n", 'TrCr,VOlg(S Insurer's Address ?, tl, Box 5oo0 Ci1y1$121977i,*0 '1_ Policy # or Self-ins. Lic. #-Ll2ubPqq -va6 Expiration Date 5 z Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to securc coverage as rcquired under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa finc up to $1.500.00 and/or one-year imprisonment, as well as civil penalties in the tbrm 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 lnvestigations of thc DIA for insurance col'eragc verification. d I do hereby certify, under the pains and penalties of perjury that the inlorrnotion provided aboye is lrue and correcl ture wr Dat t let-z,ot 2 Oflicial use onll'. Do not b'rite in this area,lo be completed by ci4. or town officitl. Phone #: 3.E Ciry/Town Cterk 4.ELicensing Board Citv or Tou n: lssuing Authority (check one): l[Board of Health 2.! Building Department5[ Selectmen's Office 6. Eother Contact Person: www.mass.gov/dia Aoplicant Information Plcase Print Lesiblv 5 Permit/License # Information and lnstructions Massachusetts Gcneral Laws chaptcr 152 rcquircs all cmploycrs to provide workers' compensation for their cmployees Pursuant to this statute. at enployee is dellned as "...every person in the service ofanother under any contract ofhire. express or implied, oral or written." MGL chapter 152, $25C(6) also stales thal "everv stat€ or local licensing agency shall n'ithhold the issuance or renewal of a licensc or permit to operate a busincss or to construct buildings in th€ commonwealth for any applicant who has not produced acceptable evidence of compliatrce with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contracl for the perlormance ofpublic work until acceptable evidence ofcompliance with the insurance requiremcnts of this chapter have bccn prescnted to the contracting authorit_v." 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. Limitcd Liability Companies (LLC) or Limited Liabitity Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Ifan LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the alfidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Depanment oflndustrial Accidents. Should you have any questions regarding the law or if you 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 Olficials Please be sure thal the amdavit is complete and printed lcgibly. The Department has provided a space at the bottom of the aflidavit for you to fill out in the evcnt the Office of lnvestigations 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. ln addition, an applicant that must submit multiple permiVlicense applications in any given year, need only submit one afiidavit 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 proofthat a valid alfidavit is on file for future perrnits or licenses. A new affidavit 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 permil to bum leaves etc.) said person is NOT required to complete this aflidavit. 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 Department of Industrial Accidents Oflice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02lll-1750 Tel. (857) 321-7406 or l-877-MASSAIE Fax (617) 727-7'749 Form Revised 7,20 t 9 wwwmass.gov/dia An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the rcceiver or trustee ofan individual, partnership. association or other legal entity, employing employees. However. thc owner of a dwelling house having not more than three apartments and who resides therein, or the occupant olthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on thc grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."