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HomeMy WebLinkAbout2025-26(/h-N0,IooS0 g HHN- z4-31LICENSE FEE SI50 TOWN OF YAR}IOUTH BOARD OF HEALTH 6 HANDLING AND STORAGE OF TOXIC OR HAZAR.DOUS MATERIALS LICENSE APPLICATION ETE THIS APPLICATION AND R-ETURN IT WITH THE LICENSE FEE BY JUNE 30. 2025TH OEF -co PLE,A.SE COMPLETE ALL QUESTIONS NAME oF BrrsrNESS /// A' z,;fl p$; BUSINESS TEL, #r'-ll BUSINESS ADDRESS IN yARMoUTtt 2o &.oa u-4 4 '/o * y.^4 /rt MAILINGADDRESS /o. Dux /eto Jlt a q....-/4 T ,4,+7 EMAIL ADDRLSS t^t /,,,t/2,-t 24. *t- EEIQIJIE.ED MANAGER,/CONTACT PERSON TELEpHSNE# fot- 7Jz. 7zo7 er=.tu1, RFOUIRI'N OWNER NAME HoME ADDRESS t,'> rEL.# ro2' 7)v- ?zt / /J. y'-r26- Vqn Va..4 tot.l /*l- CORPORATION NAME (IF APPLICABLE) coRPoRATroN ADDRESS I '(r t,2o Ir< TEL. # "fDt . , //- ,rb r-/ G,"-,--l tA 4-< /e-yft ,r,t-*- MAILTNG ADDRESS 2 o. Vu < /d lo ,f" -t< 4*4< ./1,1 tVo?){foy77 LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JTINE 30. FAILURE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT L]NTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEI\'ED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIR-ED PRIOR TO REOPENING. Town of Yarmouth taxes and ljens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes-l no- nla- Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmoulh 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 Aflidavit. If not applicable, please e4p!4!q REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON I.'ILE V N YN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RFNEWAI- APPI-ICATION APPLICANT'S SIGNATUR-E NEW APPLICATION 27 >rDATE: L 4,u- / ,<tictle 0t A. //,- TAX ID (FEIN OR SSN) REOUIRED Oh No. A0o?? LTcENSE FEr-. $r50 EHI#44V-3 Z TOWN OF YARMOUTH BOARD OF HEAI,TH 2025/2026 HANDLING AI{D STORAGE OF'IOXIC OR IIAi'ARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 ':e;$iffiiiinPLEASE COMPLETE ALL OUESTIONS NAME oF BUSINESS a/' /l'" (t"//z Zrc BUSTNESS TEL. t l?? - t, /. fV r-) BUSINESS ADDRESS IN YARMOUTI r O.L"ul ,r/- to-i /W- *, MAILINGADDRESS P u. Our t2to D.n c..-, /l ./Vl EMAILADDRESs u A) #',' @ c zr/. ,n- f BEOSIB,EDMANAGER/CONTACTPERSON E.?.+ TELEPHSNE # ,rD P. -7J 7- ? ?. 7 ul )*L.: bl,,rEL.# {of- 7J/- ?7.? /1 Jra.- 17. TEL. #Jv/' ?' ? to,r 8E]QIJIBEDOWNER NAME HOMEADDRESS /O 0n Aoa ?^'.c CORPORATION NAME (IF APPLICAtsLE)/^t l. //r" CORPORATION ADDRESS YT CI po 4 7-lb'x MATLING ADDRESS /1 c 2u t 2 t c 'fo'a ,L1/t TAX ID (FEIN OR SSN)REOIJIRED olJ/?o*7" LICENSES RLN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO R.ETI]RN THE COMPLETED APPLICATION(S) AND REQTJIRED FEE(S) BY JTINE 30. FAILLTRE TO DO SO WILL RESULT IN CLOSURI OF YOUR ESTABLISHMENT I.INTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE R.ECETVED, A HEARING BEFORE THE BOARD OF HTALTH MAY BE REQTJIRED PzuOR TO RIOPENING. Town of Yarmouth taxes and lisl appropnately if paid'. yesl s must be paid prior to renewa! or issuance ofyour permits. please checkno nla Under Chapter 152, Sec. 25C, subsection 6, the To license or permit to operate a business ifa person or insurance. As part ofthe renewal or issuance ofyou wn of Yannouth is required to hold issuance or renewal of any company does not have a Certification of Workers Compensation rpermits, you must complete the enclosed Workers explain:Compensation Affidavit. lf not applicable, RECISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKXRS COMP AFFIDAVIT ENCLOSED ALL SAFEry DATA SHEETS ON FILE N YNANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE IIEALTH DEPARTMENT. RENEWAL APPLICATION V/ NEW APPLICATION APPLICANT'S SIGNATURE DATE: b ar i--The Commonwealth of Massachusetts Departm e nt of I n d u strial Accide nts Office of I n vestig atio n s LafaYeae Ci4, Center 2 Avenue de Lafayefte, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses II\ EI Business/Organization Name:l,/ /,,(r J,y'JL Address: / o. ?)oa r 2/o City/State/Zip:12. -a A,,r.t o26t/ phone#: fO* 2/f- ror/ Business Ty'pe (required) Retail Restaurant/Bar/Eating Establishment Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainment 5 6 7 8 9 10.! Manufacturing I l.! Hcalth Care t z. EI'other nb *Any applicant thal checks box #l musl also fill out the section belou showing their wo.kerc' compensation policy information.**lf the corporate officers have exempted themselves. but the corpomtion has olher employees, a workers compensation policy is required and such an organization should check box #1. Are yg( an employer? Check the sppropriate box: -. L d I am a employer with - emplo trr, $/unaor part-time).* 2 3 4 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exerciscd their right of exemption per c. 152, Q I (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 am an employer thal is providing workers' compensalion insurance for my emplol'ees. Below is the policy inlormation. Insurance Company Name t." **{- Insurer's Address: /a, lut '?Pft70 City/State/Zip t?/- t /.1 /f / /? Policv # or Selt'-ins. Lic. #!?(/ tu.. r?'7) ?J Expiration Date .Ltt rt Zr- Attach a copt.. of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure Io secure coverage as required under g 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 of this statemenl may be forwarded to the Office of lnvestigations of the DIA for insurance coverage verification. Si Date: 6 *L tr Phoue 4 fDt - 7r 7- /7o / Offtcial use only. Do ,tot |r,ite i this area, to be compleled by ci4' or town official. lssuing Authority (check one): lfiBoard of Health 2.E Building Department 3^ECity/Town Clerk Contact Person: Phone #: Permit/Licens(r # 4. E Licensing Board Ciry* or Town: 5[ Selectmen's Office 6. Eother www.mass.govldia ,\pplicant lntbrmation Please Print l-esibh I do hereby certify, under the pains and penalties of perjury that the information provided above is tue and correcl.O--- Information and Instructions Massachusetts General Laws chapter 152 requircs all employcrs to provide workers' compensation for their employees. - Pursuant to this stattte, al 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 of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee ofan individual, partnership. association or other lcgal entity, employing employees. However. the owner of a 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 appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operat€ a business or to construct buildings in the commonw€alth 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 elttcr into any contract fbr thc pcrformancc ofpublrc work until acceptable cvidcnce olr:ompliance with lhe insurancc requirements of this chapter havc bcen prescnted to thc contracting authority." Applicants Please hll out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessaryj 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. Ifan 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. Also be sure to sign and date the affidavit. 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 companics should enter their self-insurance license number on thc appropriate line. The Oflice of Investigations would likc to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a cal[. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of I nvestigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02lll-1750 Tel. (857) 121-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2019 WWW.maSS.gOV/dia City or Town Officials Plcase be surc that thc afTidavit is completc and printed lcgibly. The Dcpartment has provided a spacc at the bottom of the affrdavit for you to fill out in the cvent the Office of lnvestigations 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. ln addition, an applicant that must submit multiple permit/liccnse applications in any given year. need only submit one affidavit indicating cunent policy information (ifnecessary). A copy of the afhdavit that has been officially stamped or marked by the city or town may be provided to lhe applicanl as proofthat a valld affidavrt is on tlle for fi-rture permits or licenses. A new afhdavit must be filled out each year. Where a home owner or cilizen is obtarning a license or permit not related to any business or commercial venture (i.e. a dog licensc or permit to bum leaves etc.) said person is NOT required to complete this atldavit.