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Home My WebLink About2025-26Lt JF06'3ooo tts-bt'z_ LICENSE 6 FEE: $150.00 TOWN OF YAR.IVIOUTH BOARD OF HEALTH 2025/2026 HANDLING A}ID STORAGE OF TOXIC OR HAZARDOUS LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENS JUNE 30.202s BUSTNE''rELs?!3I+l4L- e FIEG ERPf,0s2 2 2025 H LTH DEPT Pt-F-ASI.- COMPLETE ALL OUESTIONS NAME OF BUSINESS A roqlD BUSTNESS ADDRESS rN yARMouru r d( I ?orJ < 7:K tu{r Yana*K'mt+ &(\ MATLTNGADDREs PD tsDx ?a( D<e4rd'!- & 14'f I ,lt < r(n(aj z<ns Carr- $".€{'r u;e- l$tt,Rf, QUIRED MANAGER/CONTACT rrlppuoNe *(D8'- 3?'{ - l<}5 a-LOD( (r a.-A r' (r*'*trtqro) (rC'-a.a-< REQUIRED owNsn Norrru 6JAl l<l,tr tSt<ttx h . &tc. ,rr.n K( l - Sdt+ - \a-of HOME ADDRESS D gb{ qo\ N<< 4rp ;fr- 4 utt s (aofu*r h'h* rct-.* 8q+ -*+''AOtCORPORATION NAME (IF CORPORATION ADDRESS APPLICABLE) Brf 1d( Arcrfi"TL 6lltf MAILINGADDRESS Sarr"-< lA aAolZ- 3( - na(d+A LICENSES RUN ANNUALLY FROM ruLY I TO JUNE 30. IT IS YOUR RESPONSIBILITY 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) AITE RECEIVED. A HEARING BEFORE THE BOARD OF HEAITH MAY BE REQUIRED PzuOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriatety ifpaid: yes- no- n/a- under chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any ticense or permit to operate a business ifa person or company does nol have a Certilication of Workers Compensation in.*-".. A. p* ofienewal or issuance of your permits, you must complete the enclosed Workers Compensetion Affidavit. lf not licable, please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP A,FFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE N N A.IITY NEW CHEMICALS MUST 9E RENEWALAPPL IC^TrcN Y. PRf,-APPROVf,D BY THE HEALTH DEPARTMENT. NEW APPLICATION- APPLICANT'S SIGNATURE DATE /d/,K/a{ EMAIL ADDRESS ?o rAx rD (FErN oR ssN rup 7 Y A.The Commonwealth of Massachusetts Department of Industrial Accidents Ofjic e of I nve stigatio n s I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gou/dia Workers' Compensation Insurance Alfidavit: General Businesses Print Form Business/Organization Name:<-?4*# @tllD Address: bll Q6u;1a Sg City/State/Zip,Iffi"ar rmP 6a&\ phone#: 5()S- 3{tt- l3af Are you an employer? Cbeck thgjrpproprirte bor: t ts I am a employer with \ I employees (full and/ or part-time).i 2. E I am a sole proprietor or partnership and have no ernployees working for me in any capacity. [No workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right ofexemption per c. 152, $l (4), and we have no ernployees. [No workers' comp. irsurance required]tr 4. ! We are a non-profit organization, staffed by volunteers, with no anployees. [No workers' comp. insurance req.] Buslness Type (required): 5. @Retail 6. I Restaurant/Bar/Eating Establishment 7. E Office and/or Sales (incl. rcal estate, auto, etc.) 8. ! Non-profit 9. E Ent€rtaiffnent 10.! Manufacturing I l.E Health Care tz.! Other *Any applicant that checks bor #l must also fitl out the section below sho*ing thcir *orkers' compensation policy information. **tflhe co.porate officcrs havc cxemptcd themsclves, but thc corpontion hss olhcr employees, a wortcrs' compensation policy is requirEd snd such an org.nization should check box # I . I m an employer that is p Insurance Company Name rovidine workerc' compensation insurqnce for my employees. Belo , k the policy information. , "S-€( aha .€ lns,lrer's Address, City/State/Zip Policy # or Self-ins. Lic. #Expiration Date:- Attsch s copy ofthe workers' compensation policy declaration page (showing the policy number and expiration dote). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa frne up to $1,500.00 andor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a hne ofup io $25d.OO a day against the violator. Be advised that a copy of this statement may be forwarded to the Ofiice of Sisnature Date:t,+lr &/d { ,)l Ll - sr/) -s+1/Phone Offrcial use onty. Do not write in this area, lo be complaed by city or town oficial Issuing Authority (circle one): t. Boa-ro of Heatin 2. Building Depertment 3. City/Town Clerk 4. Licensing Bosrd 5. selectmen's ollice City or Town: Permit/License #- Phone #:Contact Person: 6. Other wwrv. m6s. gov/dia Applicant Information - Ileale PrinllgCibly Investigations of the DIA for insurance coverage verification. I do hereby certify,and penalties that the inlorrnation proided above b true snd corrccl Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ernployees. Pursuant to this stafite, arr ernployee is defrned as "...every person in the service of another under any contract ofhire, express or implied, oral or written." At 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 rec€iver or trnst€e ofan individual, parmership, association or other legal entity, ernploying ernployees. However, the owner ofa dwelling house having not more than three apartnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair wort on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, $25C(6) also states that "€v€ry state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commotrwedth for rny applicstrt who has not produced acceptable evidence of complisnce with the insurance coverage required." Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence ofcompliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please hll out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, ad&ess and phone number along with a certifrcate of insurance. Limited Liability Companies (LLC) or Limited Liability Parherships (LLP) with no ernployees 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 aflidavit may be submitted to the Departnent of Industrial Accidents for confirmation of insurance coverage. AIso be sure to sign rnd dste the aflidavit. The alfidavit should be 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 ifyou are required to obtain a workers' compensalion 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 Officials Please be sure that the affidavit is complete and printed legibly. The Departrnent has provided a space at the bottom of the affidavit for you to fill out in the event the Oflice of Investigations has to contact you regarding ttre 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 perrnit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a{Iidavit is on frle for furure permits or licerses. A new affrdavit must be filled out each year. Where a home owner or citizen is obtaining a licerse or permit not related to any business or commercial vennre (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office oflnvestigations 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or I-877-MASSAFE Fax# 617-727-7749 rorm Revised ?/2010 www'mass'gov/dia Curr€nt as of: July 1, 2025MEMORANDUM OF LIABILITY INSURANCE THIS I.,IEMORANDUM IS ISSUED AS A iIATTER OF INR)RIYATION ONLY AND CONFERS NO RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDTJM, THIS MEMORANDUT,I DOES NOT AMEND, EflfND OR ALTER THE COVERAGE DESCRIBED BELOW, AflY USE. DUPUCANOfi OR DISTRIBIJT1ON OF THIS T,IEMORANDUM WITHOUT PRIOR WRITTEN CONSEMT IS PROHIBTTED, Willis Towers Watson Midw6t, Inc. l1G lvillis Of Illinors. Inc. do 26 Gntury Blld tlashville, TN 37230-5191 lJnited States of America PROOUCER ] COVERAGEc( COMPAI.IY ZURICH AI'IERICAN INSURANCE COMPANY COMPANY a AMERICAN ZURICH INSURANCE COMPANY 40142 COMPANY c SFt F INSI]RANCE COMPAI.IY D walgreens 8@ls Alliance, Inc. and Its Subsidiary Companies 108 Wilmot Road, MS 3228. Deefield. IL 60015 United States of America INSURED COVERAGES HAVE EEEN ISSUED TO THE INSURED NAI4ED AEOVE FOR THE POUCY PERIOD INOICITED, NOTWTftSTANDING AI'IY REQUIREI.IEMT, TERI4 OR CONDMON OF ANY CONTRACT OR OTHER DOCUI4ENT WTTH RESPECT TO WHICH THIS MEI{OPENDUT'I T4AY 8E ISSUED OR MAY PERTAIN, THE INSUF}NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB]ECTTO AL]. THE TERI'IS, EXCLUSIONS AND CONOMONS OF SUCH POLICIES. LIMITS SHOWN I4AY THE POLICIES OF INSURANCE LISTEO EELOW HAVE EEEN REDUCED BY PAID CLAII4S,LI TIsFOIICY EXPIRATIOI' oAtE LlitIIs tlt usD ulttcss OTHERWISE INDICATTD POLICY NUMBER POltcY EIIECTIYE OATELETTERIYPE OF II{SURANCE GENERAL AGGREGATE 5,000,0005 5 000 0005PERSONAL & ADV IN]URY EACH OCCURRENCE 5,000,000s FIRE DAT4AGE (Anv One F Ie)500,000s MED EXP (Anv One Person)s 0 $ s 7lu20z6 7ltl2026 GLO 9310091 22 GLO 9310184 22 (Pue.to Rico) 7111202s 7trl202sCOM I.IERCIAL GENERAL LIAB]LTY Banket additional Insured Per Policy X Elanket Contractual Liability x LIABILITY (rcCURCLIII,IS MADE uquor uability COI4EINED SINGLE LIMTT $ 10,000,000 BODILY INIURY (Per Person)6 BODILY IN.IURY (Per Acodent)5 PROPERTY DAMAGE s 1lrl202s 11112025 7lt/2026 7 tuz026 MP 9310(M 22 8AP 9310183 22 (Puerto Rico)ANY AUTO AIL OWNED AUTOS SCHEDULEO AUTOS HIRED AUTOS NON.OWNED AUTOS I-IABILITY PFR ClAIlvl 5 5AGGREGATE 5 EXCESS LIABILITY-_luMsntrLA ronM lorHER rHAt !MBREur FoRn WORKERS CO14PEN'CTION uMm 2,000,000$EL EACH ACCIDENT 2,000,000sFL DISEASE - POLICY LIMTT 2.000.000s 71rt2026 EL O]SEASE . EACH EMPLOYEE | |2026wc 9310092 23 (AOS) wc 9310094 23 (Wr) EWS 9310448 23 (MA) wc 8198466 03 (t4N) WORKERS COMPEI{SATIOI{/ EMPLOYERS LIAAILITY PARTNERs/EXECUTIVE OFFICERSARE: B 10.000_000sFA'H OCCI]RRENCE 10.000,0005AGGREGATE 1111202611u2025Self-lnsuredPRODUCT LIABILffYc OWNER9TfSSORS/LANDLORDS AND THEIR RESPECTTVE AGEI'ITS, LENDERS, MORTGAGEES' GROTJNO LESSORS' VENDORS' CUSTOMERS' iUiNNi, E*-O ETIi OTNCR PARNES ARE AUTOMATICTLLY ADDED A5 ADDMONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE, COI,ITRACT OR OIHER WR]TTEN AGREEMENT. THE ABOVE POUCIES I}ICLUDE AN AUTOMANC WAIVER OF SUBROGATION A5 REQUIRED BY A SIGNEO LEASE' COI'ITRACT OR OTHER WRITIEN AGR€EMENI' FORMATIONINADDITIONAL modilicationsdateslimitglistpolicies,Th€ 16535 'IATUTORY filtrcr flr,,cr