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Home My WebLink About2025-26Dp a\aq . )3. ls..qLICENSE FEE SI50 TOWN OF YARMOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION CONIPLETE THIS APPI,ICATIOTNAN.DRETTIR\ IT \\ REESI UCENSE FEE BY Jt'\E 30. 2025 PLEASf,, COMPLf,Tf,, ALL OI,'ESTIONS ']I /I] , -l NAMEoFBUSTNESSU, *^JL (or.lor0olo,-, urr^JEE4bl.,,et7-(Yt it/ /^BUSINESS ADDRES MAILING ADDRESS YARMOUTH k*1- th,t,,v EMAIL ADDRESS RFOUIRED MANAGER/CONTACT PERSON rsrepuoNe * (e 11 -0V o- 3 o rq tsEtQllts"t l) owNER NAME HOME ADDRIjSS CORPORATION NAME (IF APPLICABLE) CORPORATION ADDRESS TEL 02v- A/L UUt ir/-lZ TEL. # r'.4a 4 TAX ID (FEIN OR SSN)REOUIRED O)Z V O L3 9Y LICENSES RLIN ANNUALLY FROM ruLY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLTNE 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. Compensation AffidaYit. If nor applicabl e, please explain Town of Yarntouth taxes 4qd Iiens must be paid prior to renewal or issuance ofyour permits. Please check appropriately if paid:(ffi--) no_ rva- Under Chapter I 52. Sb--'-. 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 docs not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed workers REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKIRS COMP AFFIDAVIT ENCLOSED _g=+LY/ NALL SAFETY DATA SHEETS ON FILE A)NANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEAI,TH DEPARTMENT. RENEWAL APPLICATION NEW APPLICATION APPLICANT'S SIGNATURE \.,i \4AILING ADDRESS ,oru,0l/2f =:= 1'.-il Please Print Le iblAoolicant Information Business/Organization Name' - City/State/Zip:Phone #: must also fill out the section belo* sho*ing their \rorkcrs'conrpcnsation policy infomlation emptcd themselves. but the corporation has olher employees. a workers' compensation policy is requircd and such an+Any applicant lhat checks box #l **lfthe corporate officers have ex organiiration should che{k box #1. Are you an employer? Check the appropriate box: l.! I am a employer with or part-time).+ employees (full and/ 2.fl I am a sole proprietor or panncrship and have no employees working for me in any capacity [No workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c. 152, $ I (4), and we have no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, 3 4 with no employees. [No wotkers' comP. insurance req.] Business Type (required) Retail RestaurantrBar/Eating Establishment Office and/or Sales (incl. real estate' auto, etc ) Non-profit Entertainment 5. 6 7 8 9 10.! Manufacturing lln Health Care D.Vo ther C.4.1 1 - ) City/Stateizip: I am an employer that is providing workers' compensution insurance lor my employees'Below k the policY information. Insurance ComPanY Name Insurer's Address: the DIA for insurancc coverage verification Policy # or Self-ins. Lic. # Expiration Date:- Attach a copy of the workers' .o.-p"n.rtion pAicy declaration page (showing the policy number and expiration date)' Failure to sccr.ue covcrage as required under $ 254 of MGL c. I 52 can lead to the irnposition of criminal penalties of a 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 $250.00 a day against the violator. Be advised that acopyoithis statement may be forwarded tothe Office of Investigations of I do hereby , under the ins and penalties of perjury that the inlotmtTion provided above is lrue and conecl. S 1-g -o90 bl)Phone #? Olficial use onty. Do not write itt this arco, to be co"'pleted by city or town sfl Selectmen's office 6' Eother Permit/License # Phone #:Contact Person: 3.E City/Town Clerk 4'ELicensing Board officiol. lssuing Authoritv (check one): 1flBoard of Health 2.E Building D€partment www.mass.gov,/dia The Commonwealth of Massachusetts Department of Industial Accidents Ollice of Investigations LafaYette CitJ) Center 2 Avenue de Lafayette, Boston, MA 02IlI-1750 wwt$t,mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses tr tr tr Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empioyees Pursuant to this statute, an employee is detined as "...every person in the service ofanother under any contract ofhire,express or implied, oral or written." An employer is defined as "an individuat, partnership, association, corporation or other legal entity, or any rwo or moreof the foregoing engaged in ajoint enterprise. and including the legal representativ., ufu d".eu."d employer, or therccciver or trustee of an individual. partncrship, association or other legal cntity, emplolng employees. Howcver. theowner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthedwelling house ofanother who employs persons to do maintenance. construction or repair work on such dwelling houseor on the grounds or building appurtenant thereto shall not becausc ofsuch emplolment bc deemed to bc an cmpioycr.,, MGL chapter 152. $25C(6) also states that "every state or local licensing agency shall withhold the issuance orrenewal of a license or permit to operate a business or to construct buildings in the commonwealth for anyapplicant who has not produced acceptable evidence of compliance with the insurance coverage required.,,Additionally, MGL chapter 152, $25C(7) states "Neither the commonwealrh nor any of irs politicaliubdivisions shallenler into any contract for lhe perlbrmance ofpublic work until acceptablc evidence ofcompliance with the insuranocrcqurrements ol this chaptcr havc becn prcscnrcd .o thc cootr.tcting authoflty... -4.pplicants Please fill out the workers' compensation aflidavit completely. by checking the boxes that apply to your situation and. ifnecessary, supply your insurance company's name, address and phone number along with a certificate of insurance.Limited Liability Companies (LLC) or Limitcd Liability Partnerships (LLP) with no employees other than the membcrsor partners, are not required to carry workers' compensation insurance. Ifan LLC or LLp does have employees, a policyis required. Be advised that lhis affidavit may be submitted to the Department of lndustrial Accrdents tbr confirmation ofinsurance covcrage. Also be sure to sign and date the alfidavit. The aflidavit should be retumed to thc city or townthat the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should youhave any questions regarding the law or if you are required to obtain a workers' compensation policy, please call theDepartment at the number listed bclow. Self-insured companies should enter their self-insurance license number on thcappropriate line. City or Town Officials Plcase be sure that the affidavit is complete and printed legibly. The Department has provided a space at the boftomof the affidavit for you to fill out in the event the Officc of lnvcstigations has to contact you regarding the applicant.Please be sure to fill in the permit/license number which will be used as a reference numier. liaddition, an applicant thatmust submit multiple permit/licensc applications in any given ycar, need only submit one affidavit indicating currentpolicy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or townmay be providcd to thc appliuallt as proolthat a ralid aI'lldavit is on file for futurc permits or licenscs. .A. neu,affidavitmust be filled out each year. where a home owner or citizen is oblaining a license or permit not related to any businessorcommercial venture (i.c. a dog license or permit to bum leaves etc.) said person is ilOT required to comptete thisaffidavit. The office of Invcstigations would likc 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, lelephone and lax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston. MA 02111-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 www.mass.gov/diaForm Rcvised 7'2019