The URL can be used to link to this page

Home My WebLink About2025-26!o 56.u0 - tltL ---'--1 :0VE- i LTSENSE FEE $r50 Fnt*l -zS- t932 l^ i TOWN OF YARNTOUTH EOARDOFHEALTH z&dtzozo ualoltxc AND sroRAGE oF Toxrc oR HAZARDous MATERTALS TH D5- - I.ICENSE APPI.ICATION ---€MfLETE THIS APPLICATION AND Rf,TURN IT WITH THE LICENSE FEE BY JUNE 30, 2025 PLEASE CONIPLETE ALL OUESTIONS NAMESFBUSTNESS VAZDS(AQZ- A eU-k P DL?,,.^.r.. r.r. o BUSNESSADDRESSINyARMouTH 32,1 L,ol+lr6 ?,MU {,,1 *lUafU -9fu;il.D aDB- 3qg -q all MAtI-ING ADDRESS S-tVvvt-u- r\< \ODJE EMATLADDRESs .1 cu-rl,5c-a*ubd\a-@ C-p"*-o,ct J-. rnrf OZUG .t r RFOUI RED MANAGER/CONTACT PERSON .-_r^Jzl\-re-,1 1- ct-rrr cLn-r-\-\ TELEPHONE #{D0. 31O-q}r-l BL[!.UIB[.DOWNER NAME {LJ-{r L .TEL,#SDg->7.1-9 Qro HOME ADDRESS 11oq,[*-LoA 6 CORPORATION NAME (tF APPLICABLE)Y,vz.DsCrAP6LA+tDscM tN6+ rLttt TEL, 'J 90K- coRpoRATToNADDRESS |altrV X B ur.a r^)es S happgl D /^)C 3q8 -,1 >-17 MAILING ADDRESS AS uu5 zA)€sJ )LE-SS OL\17 4Vt31 LICENSES RT]N ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) ANTD REQUIR.ED FEE(S) BY JLINE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT LINTIL 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 li s must be paid prior to renewal or issuance ofyour permits. Please checkno nJaappropriately if paid Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any license or permit to operate a business ifa person or company does not have a Cenification of Workers Compensation insurance. As pan ofthe renewal or issuance ofyour permits, you must complete the enclosed workers('om ensation Affidavit. If not a licablc lcasc ex lain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKTRS COMP AFFIDAVIT ENCLOSED ALL SAFET}' DATA SHEETS ON FILE YNPRE-APPROVED BY THE HEALTH DEPARTMENT. \ ANY NEw cHEMrcars uusTi6r RENEWAL APPL''O''OA V APPLICANT'S SIGNATURE NEW APPLICATION DATE rAX rD (FEIN on ssNlBE@IED 1-)-)oAf \1 The Commonwealth of Massachusetts Dep artm e nt of I n d u strial A ccide n ts Ollice of Investigations Lafayette City Center 2 Avenue de Lafayene, Boston, MA 021I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name:YAaDscAf € - h€LL N ?oorS Address: be1 LD lkr Tu3 9A-fl+r a rl CiiylSrarc/Zip are /rM u an employer? Check appropriate box: I am a employer with employees (full and./ 2 or part{ime). * I am a sole proprietor or partnership and havc no employees working lor me in any capacity. [No workers' comp. insurance required] We arc a corporation and its officcrs have excrcised their right ofexemption per c. 152, S I (4), and we have no employees. [No workers' conrp. insurance required]** Wc are a non-profit organization. staffed by volunteers. with no cmployees. [No workers' comp. insurance req.] -l 4E Business Type (required): 5. ! Retail 6. E Restaurant,Bar/Eating Establishment 7. 8. 9. l0 lt Office and/or Sales (incl. real estate, auto, etc.) Non-profit Entertainmenl Manufacturing Health Care 12.(other CAtt-ilz*<-qa(- *Any applicant that checks box # I must also fill out the section below showing their workers' coopensation policy information.**lf the corporate officers have exempted themselves, but the corporation has other employees, a wotkers' compensation policy is required and such an organization should check box #l I tm an employer that is providing workers' compensolion insumnce for my employees. Below is the policy information. Insurance Company Name UOgzc-o Insurer's Address 1 1.,,O a-t o. A S,-r City State Zip )Dw-r' bg lqqo'l Policy # or Selt'-ins. Lic. #\,\)roL31Kq to| |Expiration Date b44.a Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to sccure covcragc as rcquired 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 $250.00 a day against the violator. Be advised that acopy of this statement may be forwarded tothe Office of [nvestigations of the DIA for insurance coveragc verification. I do hereby , under the pains d penalties of perjury lhal the inlornration provided above is tue and correct. S ature Dare: 1-)-2 oa{ Phone #'-ot' 31s - q)11 O!ficial use on$'. Do ,rol b,rite in this area, to be completed by cirr* or town o/ficial. lssuing Authority (check one): tEsiara of Heatttr Z.E SuitOing Department 3[ Ciry'/Town Clerk 4.ELicensing Board Contact Person: Phone #: Permil/Licensc # 5[ Selectmen's Office 6. !Oth€r www.mass.gov/dia Applicant Information Please Print Lesiblv Citv or Town: An employer is defined as "an individual, pannership. 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, partncrship. association or olher legal cntity, cmploying employees. Howevcr, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainlenance, 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 chaprer 152, g25C(6) also states thal "every state or local licensing agency shall withhold the issuance or rencwal of a liccnsc or p€rmit to opcrate a busincss or to construct buildings in the commonwealth for any applicant who has not produc€d acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, {25C(7) states "Neither the commonwealth nor any of its political subdivisions shall entcr into any contract for the pcrlbrmancc of public work until acceptablc evidencc of compliance with the insurance rcqriircmcnts of this chaptcr havc bceii prc.icittcd to tl'tr co tracting authurity." Applicants Please fill out the workers' compensation affrdavit 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 ofinsurance. Limited Liability Companies (LLC) or Limited Lrability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Ilan 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 coverage. Also be sure to sign and date the alfidavit. Thc affidavit should be rctumed 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 ifyou are required to obtain a workers' compensation policy, please call the Dcpartmenl at the number listcd bclow. Self-insured companics should enter their sclf-insurance license number on the appropriatc line. City or Town Officials Please be sure that the affidavit is completc and printcd legibly. The Dcpartment has provided a space at the bottom of thc affidavit for you to fill out in the event the Office of Invcstigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. tn addition, an applicant that must submit multiple permiVlicensc applications in any givcn year. need only submit one affidavit indicating cunent policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicanl as procfthat a .,'alid affid:r' it is on filc for futr:re permits or licenses. A nerv affidevit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not relaled to any business or commercial venture (i.e- a dog license or permit to bum leaves etc.) said person is NOT rcquired to complete this affidavit. The Office of Investigations would like to thank you in advancc 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 Lafayette City Center 2 Avenue de Lafayette, Boston, MA02ll1-1750 Tel. (857) 32r-7406 or 1-877-MASSAFE Fax (617) 727-7749 Fo.m Revised 7/2019 www.mass.gov/dia Information and Instructions Massachusetts General Laws chaptcr 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."