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Home My WebLink About2025-26c,Laslq rsoRH l+-23- |LICENSE FEE $ TOWN OF YARJUOUTH BOARD OF HE.ALTH 202512026 HANDLING AND STORAGE OF TOXTC OR HAZARDOUS MATER]ALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT }I'ITH THE LICENSE FEE BY .IUNE 30, 2025 ,?_\ 9sc,ll;;;:D Yq,/ fntzqKotFo PLEASE COIITPLETE ALL OUESTIONS NAME Ot-' BUSINESS BUSINESS ADDRESS IN YARMOUTH MAILINC ADDRESS EMAIL ADDRESS BUSINESS TEL. # I BI,OLIBED MANAGE R/CONTACT PERSON TELEPHONE #717 RFOTiIRt'D OWNER NAME TEL,# HOME ADDRESS CORPORATION NAME (IF APPLICABLE)rcr.* ?6<V(a7 ?o CORPORATION ADDRESS MAILING ADDRESS TAx rD (r--ErN oR ssN)REOUIRED -%? ihq o\e LICENSES RUN ANNUALLY FROM JULY I TO JLNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLTNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT L,]NTIL 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 of your permits. Please check 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 Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed workers Compensation Affidavit. lf not applicable, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AIFIDAVIT ENCLOSED ALL SAFEry DATA SHEETS ON FTLE Y N YNANY NEW CHEMICALS MUST BE PRE-APPROVED BY TIIE HEALTH DEPARTMENT. RENEWALAPPLICATION- NEWAPPLICATION APPLICANT'S SIGNATURE DATE { tr:. z{ The Commonwealth of Massachusetts Dep artment of I n du strial Accidents Of/ic e of I nves ti g atio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name : Address: CitylState/Zipi o Phone #:So8 3q{ o78o 5. 6. 7. 8. 9. l0 Business T1-pe (required) Retail RestauranL/Bar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment Manufacturing I L! Health Care 12.ffi other *Any applicant that checks box #l musl also fill out the section below showing their workers'conlpensalron policv informationt*Ifthe corporate officers have exempted themselves, but the corpomtion has other employees, a workers' compensation policy is required and such an oiganization should check box #1. Ar€ you an employer? Check the a or part-lime).* Z. E t am a sole proprietor or pannership and have no employees 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, $l(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.] I ppropriate box: R- I un, a employer with employees (full and/ 3 4 I tm an employer thal is providing h,orkers' compensttion insurance for my employees. Below is the policl, informotion. Insurance Company Name lnsurer's Address City/State/Zip Policy # or Self-ins. Lic. # Expiration Date:_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coveragc as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa 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 OfIce of Investigations of the DIA for insurance coverage verification. I do hereby certify,der the pains and penalties of perjury that the information provided above is true snd coruecl ture Da Phone #SoE 3Q ( orSO Ollicial use only. Do not write in this area, to be compleled by ci.r* ot town oJficial. Permit/Licensc # Phone #: 3.E City/Town Clerk {. E Licensing Board lssuing Authority (check one): lflBoard of Health 2.f] Building Department 5E Selectmen's Office 6. f]Other Contact Person: Annlicant Information Please Print Lesiblv Citr or Town: www.mass.govldia Massachusetts General Laws chapter 152 rcquires all employcrs to provide workers' compensation for their employees Pursuant to this statute, ^n employee is defined as "...every person in the service ofanother under any contract ofhire, express or implied, oral or written." An employer is defined as "an individual, pannership, association, corporation or other legal entity, or any two or more ofthe loregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the receiver or tnrstee ofan individual, partncrship, association or othcr legal entity, employing employees. However, the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtcnant thereto shall not because ofsuch employment be deemed to be an employcr." MGL chapter 152, g25C(6) also stales that "every state or local licensing agency shall withhold the issuance or renewal of a licensc or permit to operatc a business or to conslrucl buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, g25C(7) states "Neither the commonwealth nor any of its political subdivisions shall cnter into any contract for thc performance ofpublic work until acceptable evidence ofcompliance with the insurancc rcquiremcnts of this chapter havc bccl prcscntcd to the c(,ntracting authority." Applicants Please hll out the workers' compensation affidavit completely, by checking the boxes that apply to your sinration and, if necessary, supply your insurance company's name, address and phone number along with a certificate ofinsurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members 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 this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance covcrage. AIso 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 Department 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 listcd below. Sclf-insured companies should entcr thcir sclf-insurance license number on the appropriate linc. City or Town Olficials Please be surc thal the affidavit is complete and printed lcgibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in thc event the Office of Investigations has to contact you rcgarding the applicant. Please be sure to lill 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 affidavit indicating current policy infonnation (ifnecessary). A copy of thc affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prooithat a lalid aIfldavit is on filc fr-rr funrre permits or licenscs. A ncrv affidavit must be filled out each year. Where a home owner or cilizen is obtaining a license or permit not related to any business or cofirmercial venture (i.c. 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, Ielephone and fax number: The Commonwealth of Massachusetts Department of lndustrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette. Boston, MA02lll-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 72'7-7149 Form Reviscd ?i2019 wwV.mass.g0v/dia Information and Instructions _-\,ACORD-CERTIFICATE OF LIABILITY INSURANCE\>- COVERAGES REVISION NUMBER:CERTIFICATE NUMB ER: 192S680067 oATE lff/oo/YYYY) 6117 t2025 LT TER,HoHoLFICATEHTcERTPUNIGRTSHRENsooNocNNoLTMAloNNoRETTOFRSASUEOsLIoc sEISTEPHTERcTBYEOoHTSoFREGHTECOVERAERRoNoTEEXENt\4 o,LEGVETINORLMRTIVEFF R oOTNsHUTooFITAEREUEcTIRNSNGR(),SSUTEHENETWEBTcoNTRAUITTETNoSToNDOESNENSRAUOFTCAEEcRTFTISHEBLlJWOELRHTEoRCETtcAFDNETHUCERDR,oTTIORENEPRESR rs6dob€ndssionRUEOLNASIND0topIThavgstAi6smuthREUDpollcYLANSADDITIONats onat6holdorntcertillstatemoAItnt.ATNT m0ndorseMPORtlaleieslic16qrtanthoofpodPanh6oTINBRSUosrsendohsolUCdenclihatethrtitohtsrlfenotdoessthT ibson com 508-755-5200 eland PHONE AOD S COVERAGE an!NSURER A Marke llnsurance C INSURE INSURER C INSIJRER D REIN SURER F gASSILELO2 RTA ER ODPOLCYoTHEABOVEUDEAMEDNNSTOBEVENELBEHAOWSTLIEDNSUENCcsEoHTELocTHHsTTHATOTcETITOHRsEECTHSSN1UNETEHDOCRORTOTcNYNTRACooRoTEEMNEQUIRANOTNGLLHETNOHTSBTECTocTEDNSUSNDEDIEREHEDESSCETHICPOLoDEBcNEORETHNUSNEUDEoBETCATEERcEDCBYDRENDUEVEEBMLN4STsEHcocLOFUSAND TYPEOF INSURAIICE $ GEN'L AGGREGATE LIMITAPPLIES PER LOCI PoLlcY I I JECT OTHER $ $ GENERAL AGGRE GATE PERSONAL & ADV INJURY EACH OCCURRENCE SE MEO EXP COiII'ERCIAL GENERAL LIAEILITY ' cLett"rs-t',uoe [ ]occun AU'OUOBILE LIABIUTYL l-1 omeo T-- ScHEDULEoI arros oNLy L l AUIOST-- HicEo l lNoNow{ED I AUTOS ONLY L ] AUTOS ONLY NT LLl $ BODILY INJURY (Per Person) PERTY 5 s CIAIMS-MADE occuR EACH OCCURRENCE AGGRE6ATE DED UMERELIALIAE EXCESS LIAB 12113t242512t13t2024awc0011161'05 s 500.000E L EACHACCIDENT X oEsc DiraiN oF oPERATIoNS below DISEASE, POLICY LIMIT t 50O,OOO woRl(ERS COitPENSATIOIIA DE PLOYERS' LIASIUTY ANYPROPR ETOR-/PARINER/EXECUT]VE OFFICER/MEMEEREXCLIJDED?E L D1SEASE EAEMPLOYEE T5OO.OOO oEscRlPlloll OFOPERAT|OIiS/ LOCAIIONS / VEIIICLES (ACORO lOl. Addnio nalReh..ts Schedul.. may b..ta.hcd it oor. sPa.. as requi..d) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 1 146 Route 28 South Yarmouth MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREO IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTIORIZEO REPRESENTATIVE dHAd-,/Zrr*- O 1988-2015 ACORD CORPORATION. All rlghts reserved ACORO 25 (2016/03)The ACORD name and logo are registered marks ot ACORO or the mayoonditionstgrmstoWAIVED,subjocttf lieucertilicate PRODUCER oetanO. oiUson tnsurance Associates, lnc' 190 Park Ave Worcester MA 0'1609 INSURED Bassil Brothers United lnc 1308 Route 28 South Yarmouth MA 02664 THEISSUED CONDITIONTERIV TERIVlS CLAIMSSHO\\,NCONDITIONSEXCLUSIONS s l,_)- 5 5 $ BoOILY INJURY (Per acclde.l)