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Home My WebLink About2025-26ty 30c{'tffi1,9 B+-t+lr.,r -a3 - lloELICENSE FEE SI50 TOWN OF YAR-N{OUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZAR-DOUS MATERIALS LICENSE APPLICATION COMPLf,TE THIS APPLICATIOf{ANDXETURN IT WITH THE LTENEIY' JUN 20 2025 NAME OF BUSINESS qL4t BUSINESS TEL, 4 BUSINESS ADDRESS IN YARMOUTH aif(.taruUfL r^/)6.7s o&&) )ttf ,o MAILING ADDRESS D,rX {d(lro r-f I:MAIL ADDRESS BEqLI&ED MANAGER/CONTACT PERSON TELEPHONE #9K - 3r) -Jltt(t"fr+-Irxa u)a,lk t4- a$v-^ I lltrt bJtLlsD RFOL]IRFD OWNER NAME a TEL.4 Kq?- Sr+ -LO& HOME ADDRESS w trdrf CORPORATION NAME (IF APPLICABLE)U)n)-on u.n hla* h\ ?.-rE,-. n Kc 0 {a} - {&8' CORPORA.TION ADDRESS L dhrS MAILING ADDRESS F.o d\( h(Y TAx ID (FEIN oR SSN} REOUIRED \{ - lq}q03( LICENSES RLIN ANNUALLY FROM JULY I TO JTINE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQT,IIRED FEE(S) BY JLTNE 30. FAILTJRE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A TO REOPENING. G BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR Town of Yarmouth taxes and appropriatelyifpaid: yes ns must be paid prior to renewal or issuance ofyour permits. Please checkno n/a Under Chapter 152, Sec. 25C. subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Com ensation Affidavit. If not a cablc lease ex lain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK€RS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE ANY NEW CHEMICALS }II,ST B YN APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATIO Y .\_ APPLICANT'S SIGNATURE NEW APPLICATION DATF:d/r t/d{ The Commonwealth of Massachusells Department of Industial Accidents Ollice of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I l-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name:4 :qbl Are y9u an employer? Check the appropriate box: t.E[ I am a employer with \)-employees(full and'Z'' or part-time).* 2. E I am a sole proprietor or partnership and have no J 4 employees working for me in any capacity. INo workers' comp. insurance requiredl We are a corporation and its officers havc exercised their right of exemption per c. 152, $ I (4). and we have no employees. [No workers' comp. insurance required]** Wc are a non-profit organization, staffed by voluntcers, with no employees. [No workers' comp. insurance req.] &t+ o L?{ ?{ phone#: 5a(- 3ta - )LLL\ Busingr/Type (required): 5 EI Retail?, 6. I Restaurant tsar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. 9. l0 ll t2 Non-profit Entertainment Manufacturing Health Care Other Address:( CitylS12.rclZipl |Any applicant that checks box #l must also fill out the sec(ion belo\v showing their workers' compensation policy i[formation. .*lfthe corporate officers have exempted themselves, but the corpomlion has other employees, a workers' compensation policy is required and such an organization should check box #1. roviding workers' compenssti0n insumnce Jor my employees. Below is the policf information.I am tn employer that is p lnsurance Company Name Zu,ri0L lnsurer's Address AW*clo Rt city/state/zip ,l{JD] A Policy # or Self-ins. Lic. #A^) 5 {3oqqr}(Erpiration Date llt S Attach a copy of the workers' compensation policy declaration page (showing thc policy number and expiration dat€). failure to securc coverage as required 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 form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violalor. Be advised that acopy ofthis statement may be forwarded to the OlTice of lnvestigations of the DIA for insurance coverage verification. I do hereby certifi-, under the pains and penalties olperiury thal the information provided abot'e is true and correcl Si ture Date: (1td() s'- Phone #:) >L(- SLt) -37 a I Ollicial use onty. Do not write in this area, to be completed by city or town ollicial 5[ Selectmen's Office 6. Eother Contact P€rson: Permit/License # 3E City/Town Clerk 4.ELicensing Board City or Town: Issuing Authority (check one): tflBoard of Health 2.E Building Department wvw.mass.Sov/dia \ Applicant Information Please Print Legibly Ll*n,,ty'L Anvncot-*-h'-t r^al-et erv"-{t r,4.' Phone #:- Information and Instructions Massachusetts Gencral Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enterprise. and including the legal representatives ofa deceased employer, or the receiver or trustee ofan individual. partnership. association or other legal cntity, emplolng 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 ofanother who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be dcemed to be an employer." MGL chapter 152, $25C(6) also states that "everv state or local licensing agency shau withhold the issuance or rcnewal of a license or pcrmit to opcrate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insuratrce coverage required." Additionally, MGL chapter I 52, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enlcr into any contract for the performance ofpublic work until acceptablc evidcnce ofcompliance with the insurance rcquirements of this chaptcr havc bccn presentcd to thq coDtracting authority." 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. 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 insurancc coveragc. AIso be sure to sign and date thc amdavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested. not the Department of lndustrial 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 appropriatc line. City or Town Officials Please bc sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the a{fidavit for you to fill out in thc cvent the Oflice 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 lhat must submit multiple permit/liccnse applications in any given year, need only submit one affidavit indicating cunent policy information (ifnecessary). A copy of the affidavil that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file 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 leaves etc.) said person is NOT required to complete this affidavit. The Oifice of lnvestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to Bive 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, MA0211l-1750 Tel. (857) 32r-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/201e WWW.maSS.gOV/dia