HomeMy WebLinkAbout2025-26'Yll
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NAME OF BUSINESS
BtJSINESS ADDRESS lN YARltlOUTH I
MAILINC ADI)
LIC
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TOWN OF YARMOUTIT BOARD OT HEALTH
DLINC AND STORAGE OF TOXTC OR HAZARDOUS IITATERIALS
LICENSE APPLICA'I'ION
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PLEASE CO}IPLETE THTS APPLICATION AND RE'TURN 1T WITH Hf LICENSE FEE BI'
J UNE 30, 202-1 L /a -. . alr!-l\lil Srr..,..iJqix- 3ci?--2.slt
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BUSINESS TEI-. I
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HOME TEL. I
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28
HOME ADDRESS
I:tvlAlL ADDRT
MANACER, CONT C'T PERSON
OWNER NAME
CORPORA ION NAMI] (If A?PLICABLE)
EIN OR SSN )REOUIRED
CORPORATION ADDRESS
MAILING ADDRESS
LICENSES RUN ANN(,JALLY FROM JULY I 'TO JUNE ]0. IT IS YOUR RESPONSIBILITY TO RE'I'URN
iur CorwlerrD AppLICATION(S) AND REQUIRED FEE(S) BY JUNE 10. FAILURE To DO SO wlLL
RESULT IN CLOSURE OF YOUR ESTABLISHMENT TINTIt, THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARING BEFORE THE BO.ARD OF HEALTH MAY BE REQUIRED PRIOR
TO REOPENINC
Torvn of Yarmouth taxes and liens must be paid prior to renewa I or issuance of your permits. Please chcck
appropnately ifpaid: yes no na
Under Chapter 152. Sec. 25C, subsection 6, the Town of Yarmouth is rcquired to hold issuance or renewal of any
license or permit to operate a business ifa person or company does not have a Ce iticalion of Workers Compensation
insurance. As parl ofrenewal or issuance ofyour permits, you musl compl€le the enclosed Workers Compensltion
Amdrt il. If not applicable,olease explain
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED YN
ALL SAFETY DATA SHEETS ON FILE T
ANY NF,W CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT.
APPLICANT'S SIGNATURE
DATE 0+ -ib
NEW APP I ION
PLEASE COMPLETE ALL OUES'TIONS
tERiUDn ra Pg Co
o__
9rALYorv',o,"'lL ,M ot Ct+
RENEWAL APPLICATION /
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Depanme of lndustrial Accidents
Offt c e of I n vest i g ot i o n s
Lalayette CiO, Center
2 Arenue de Lafayette, Boston, MA 021 I l -1750
www.mass.gov/dia
Workers' Compensation Insurrnce Aflidavit: Genergl Businesses
Business/Oryan ization Name: (-4 PE rzz /znnllfiX Lra
Address:
City StateiZip:
Arr you rn emplol"rr? Chrck th propriatc bor:
F I arn a r'mploycr with cmployccs (full and./
'An) aplicrnr firl ch.cls bor I I eust !l"lf rha corpomtc omcari ha!a cx.tnptd
oBen[rtion slxBld ch.cl lxrr I I .
er: {6 -7qP- ]ztl
or pan-tim€)..
2. fl I am a sole proprietor or partnership and have no
employees uorking for mc in any capaciry.
_ [No workcrs' comp. rnsuraocc rcquired]
3. l-l Wc are a corporarion and its officers have exerciscd
thcir right ofcrernption pcr c. 152. til(4). and ue have
_ no employean. [No *orkers' comp. insurance required].
.1. ! \{'e are a non-profit organization, sralled by volunteers.
with no employees. INo uorkcrs' comp. insurance rcq.l
lso f out th( i<ctioo bclot shor{hg rhcir worlcr!' cooFdllrion Flicy ilfo.rnrtioo.
thcmsrllcs" hul fic coqhErioo has.{hcr ctrq oy(cs, a wod.cfi flrmpcrrsrti(lrt policy ts rcluircd and such m
Burloesi Type (requircd):
5. I nerait
6. ! Restauranr,lBa/Esting Esrablishrnent
7. E Oflicc and/or Salcs (incl. rcal cstarc, auro, etc.)
E. ! Non-profit
9. ! Entcrtainmcnr
t0.I Manufacruring
I l.E Health Carc
l2.E other
I om on eaplolet that is 'g worken' compentolion ifisurcneelor mJ'caplol,ces Bchtw is thcpolicy iaformotion.
lnsurancr' Cornpany Nanrc
lnsurcr's Address ?0 hox ne
Trv &
City State Zip (,*T I o 02 - o//
failurc to sccurc corcragc as rcquircd undcr $ 25A ofMCL c. 152 can lcad to thc imposition ofcriminal pcnahics ofa finc upro 31.500.00 andbr onc-year imprisonment, as wcll as civil penalties in thc form ofa STOP WORK ORDER and a fine of up ro$!50.00 a day againsr rhe violaror. Be adviscd rhat a copyofthis srarcmcnr nuy bc fonrardcd io the Oflicc of Invcstigations ofthc DIA for insurancc coveragc vcriIication
I lo hcrebt thc poins and peaalties o[pcrju4, thit thc inlorn ation pntvided obote ir tru? ond coftc..t.
O - eb- aozAg-P
usc only. Do not x,ilc in this arca, ro hc complet.d bl city or lown olficial.
lssuiDg Authorit\ (chcck oor):t[Boerd of Hertr! 2.E Buildiog D€prrrmrnt 3DCiry/Town Cl€rk:\{_l setectnten's Omce 6. Dother
Permia/Liccnse #
4. ELice nsing Borrd
Phone #:
(\liciat
( o,rtact Pcrron:
( itr or To*n:
Apolicent Information please print l,esiblv
Poricyaorserf-ins- Li, H3!-1105) ll (ft
-Expinrionoa1e:
L0 l? - 20)KAtl.ch r coPJ- of thc worlen' compcnsrtloo polic! dccltrrtion prgc (showiog thc policy oumb€r rrd erplr.tion drte).