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Home My WebLink About2025-26[h.No.2Zog3 LICENSE FEE S I50 &Htil-?3-18* OF YAR}IOUTH BOARD OF HEAI-TH 2 D STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION PLEASE COMPLETE ALL OUESTIONS -.4- NAME oF BUSINESS /fhfisrrl;s{ an {s,D 9ruc,il,'h 64ur rrrrur.o av "2'/yFOjv* Kr as C.t I t':'" rrt rtlrl- BUSINESS ADDRESS IN YARMOUTH REeEuv=, JUL 0 2 20?sTOW OO6{1IIR DE,HYC; MAILING ADDRESS 8v f738 l,uest rf{ttt t) t)llr EMAIL ADDRI]SS ,5 e ,*-/;sl atr REOUIRED MANAGER/CONTACT PERSON 77;. TELEpHoNE# $ct,Y 7il-578A &./1 { R[-OL I RF T)owNenNturZhaaffi F/u/ ,'5S)c n4. ozat5 , (Ar7/ rcr.* *)Y 22/ 5284 Houeanrnrss G 7 CORPORATION NAME (IF APPLICABLE);st) {h coRpoRAroNAoopsss /FY ff 96 best MAILING ADDRESS S rtnrt€ slrn5 1v,pt/. azal6 rt.* iay 2qn -/i,?o o 'tu4 az_a7 3 LICENSES RLTN ANNUALLY FROM JULY I TO ruNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLINE ]0. FAILURE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT LNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED, A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENTNG Town of Yarmouth taxes and lens must be paid prior to renewal or issuance ofvour permits. Please check appropriately if paid: yes 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 Certification of Workers Conrpensation insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Affi davit. lf not applicable Dlease exDlain a sto no n/a REGISTRATION FORM SIGNED .A.ND COMPLETED CHECK AND WORKIRS COMP AFFIDAVIT ENCLOSEI) ALL SAFETY DATA SHEETS ON FILE YN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION NEW APPLICATION Z N APPLICANT'S SIGNA DATE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 TAX ID (FEIN OR SSN) REOUIRED , of,*/a' The Commonwealth of Massachusetts Department of Industiol Accidents Oflice of Investigations Lafayette City Center 2 Avenue de Lafoyette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name s n;5 o,'r-1;t/'s (- Address:*T Ag VJvst'fr{r}4Orh City/State/Zip ,/l oab73 Phone #:5oX I 2 Are vou an employer? Check the appropriate box: I am a employer with JE mployees (full and/ or part-tirne), + I am a solc proprictor or partncrship and havc no employees working for mc in any capaciry. [No workers' comp. insurance required] E. E We are a corporati,on and its officers have exercised their right of exemption per c. I52, {l(4), and we have no employees. [No workers' comp. insurance required]+4.! We are a non-profit organization, staffed by volunteers, with no cmployees. [No workers' comp. insurance req.] ?o . /rEc Business Tvpe (required) Retail I."+^".^-t-e-'/Eari _ Office and/or Sales (incl. real estate, auto, etc.) Non-profit 5. 6. 7. 8. 9. ! Entertainment Manufacturing Health Care Other t0 u t2 *Any applicanl thal checks box # I must also fill out thg section b€low showing their workers compensation policy information.**lfthe corporate olficers have cxcmpted thenNelves. but the corporation has other employees. a workers' compensation policy is required and such an organizalion should chcck box #1. I am an enployer that is proviling workers'compensation insurance lor my employees, Below is lhe policy information, Insurance Company Name 4 o lLr r'= Insurer's Address: P O o 6 Ciry/State/Zip NY l+e-q0 - tfbw8'., {l* ln Policy # or Self-ins. Lic, # 41 o8^A.7-Af Attach a copY of the workers'compensation policJ.declaration page (showing the policy number and erpiration date). Failure to secrue covcragc as rcquircd undcr $ 25A of MGL c. 152 can lead to the imposition of criminal penaltics ofa finc 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 tine of up to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded lo lhe Office of Investigations of the DIA for insurance coverage verification. C - zUr Expiration Date I do hereby S ture ( ertl , under the pains o penalties of perjury lhat the information provided a is lrue a d correct.a€ Phone #5o8 a9o /aKc Olficial use only. Do not write i this uea, to be completed by cirr^ or town ollicidl. Issuing Authority (check one): lflBoard of Health 2.E Building Departm€nt 3.8 Ciry/Town Clerk Permit/License # 4. E Licensing Board Citv or Town: 5[ Selectmen's Office 6. lother w*w.mass.gov/dra rl'- .\pplicant Inlbrmation Pleasc Print Legibh Contact Person: Phone #: Information and Instructions Massachusetts General Laws chaptcr 152 rcquires all cmployers to provide rvorkers' compensation for their employees. Pursuant to this slatJte. aD employee is dehned as "...every person in the service ofanother under any contract of hire. express or implied, oral or written." An employet is defined as "an individua[, partnership, association, corporation or other legal entity, or any two or more ofthe fbregoing engaged in ajoint enterprise. and including the legal representatives ola deceased employer, or the rcccivcr or trustee ofan individual, partnership, association or other legal entity, employing employees. However. the owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the dwelling house of another who employs persons to do mainlenance. conslruction or repair work on such dwelling house or on the grounds or building appurtcnant thcrcto shall not bccause of such employmcnt be deemed to be an employcr." MGL chapter 152, $25C(6) also states that "every stat€ or local licensing agency shrll withhold the issuance or rencwal of a license or permit to operatc a business or to construct buildings in thc commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall entcr into any contract for thc pcrformancc ofpublic work until acceptable evidencc ofcompliance with the insurancc requrremcnts of this chapter havc bccn prcscnted to the contracting authority." Applicants Please hll out the workers' compensalion affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name. address and phone number along with a certificate ofinsurance. Limitcd Liability Companies (LLC) or Limited Liability Pa(nerships (LLP) with no employees other than the membcrs or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that thrs affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurancc coverage. Also be sur€ to sign and date the aflidavit. The affidavit should bc retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on thc appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Deparment has provided a space at the boltom of thc affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/licensc applications in any givcn ycar, need only submit onc aflidavit indicating currcnl policy information (ifncccssary). A copy ofthe affidavit that has bccn officially stampcd or marked by the city or to$'n may be provided to fie applicant as proof that a valid allidar it is on fiic for future 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 lcaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would likc to thank you in advancc 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 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02 I I 1- I 750 Tel. (857) 321-7406 or l-S77-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 wWW.maSS.gOV/dia ^-.,TRAVELERSJ ONE TOWER SQI'ARE IIARTFORD CT O 5183 INSURED: TRANSI{ISSION SPECIAIISTS. INC. 188 ROIIIE 28 w YA.RMOrrrE, MA 02573 INSURER: TEE TRAVEI.BRS IITDBINTTY CO PNIY OP CONNECTICITT A stock C@P.DY 1. TYPE V INFORMATION PAGE WC OO OO 01 ( A) POLICY NUMBER: rrB-4ir47 015L-24-42 -C RENEWAL OF (rrB -4.147 01SL-23 -42-Gl NCCI CO CODE: 12537 PROOUCER: SG & D INS AGEITCIES LLC 10 INSTITME RD rcoRcEsTER, uA 01509-2756 lnsured is A coRPoRATrolr Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-27 -24 lo 08-27 -25 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: t{A B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily lnjury by Accident: $ 100,000 Each Accident Bodily lniury by Disease: I s00, 000 Policy Limit Bodily lnjury by Disease: $ 100, 000 Each Employee C- OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AR AZ CA CO CT DC DE FI. GA EI Il' ID IL IN KS KY LA IID XE UI IIN tTS tiT NC NE NE N.' NU NV M' OR OR PA RI SC SD TN TX I'T VA 1':T WI D. This policy includes these endorsements and schedules: SEE I.ISTING OF ENDORSETM|TS - EXTBISION OT INFO PAGE 4. DATE OF ISSUE: 07-u-24 sD OFFICE: SPRINGFIEIJD MA 354 PRODUCER: SG & D INS AGENCIES LLC RW3OO AI li{O wv The premium for this policy will be determined by our Manuals of Rules, Classmcations, Rates and Rating Plans. All required inform;tion is subject to verification and change by audit to be made ANNUAILI WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY