The URL can be used to link to this page

Home My WebLink About2025-26REGE]!:=f h.t/0. llt22 JUL q 3 2025 HEALTH DEPT LIT'IJNSE FEE S I50 BHf/a-,?3-/?ot PLEASE COMPLETE ALL o ONS NAME OF BUSINESS S BUSINESS ADDRESS IN YARMOUTH o8s- Ro.r Jtr SS TEL 9SilrdilID r s&31tr 3,.JtF s MAILING ADDRESS o ,l EMAIL ADDRESS t 8,t{)gIBED MANAGER/CONTACT PERSON J\ . Corn t.#s(*-.?1t- xq4 GY CDL'|3 TELEPHONE #?'71 -Jt11 )1,{ D} os-Jt BfloulBEDolvN HOME ADDR.ESS ER NAME TE <. CORPORATION NAME (IF APPLICABLE)TEL. # CORPORATION ADDRESS MAIt-ING ADDRESS Nrflo "t+L 1 TAX ID (FEIN OR SSN)REOU IRED t? LICENSES RLN ANNUALLY FROM JU LY I TO JLNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JL]NE 30. FAILURE TO DO SO WILL RESI,'LT IN CLOSURE OF YOUR ESTAB LISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPEI-ING Town of Yarmouth tax s must be paid prior to renewal or issuance ofyour permits Please checkes and ligt{ye\zappropriately ifpaid no-nla_ 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 Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Affidavit. lf not aoolicable, plcase cxplain:( ompensation REGISTRATION FORM SIGNED AND COMP LETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA ST{EETS ON FILE ANY NE\\' CHEMICALS }IUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION * APPLICANT'S SICNATI.IRE NEW APPLICATION- DATt: TO\I'\ OF YAR}IOUTH BOARD OF HEAI-TH 2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZAR.DOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETLIRN IT WITH THE LICENSE FEE BY JUNE 30. 2025 <- N N The Commonweahh of Massachusetts D epartment of I n du strial A ccide n ts OfJi c e of I nvestigatio n s Lafayette City Center 2 Avenue de Lafoyette, Boston, MA 021I I-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses mation Please Print LAlicant lnfor bl Business/Organization Name: eddress:L&,( e*;f Po'-;6'7 CitylState/Zip u.eoO Are v 'pzfl ou an employer? Ch€ck the appropriate box: I am a employer with or part-time).* employees (full and/ 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 otficers have exercised their right of exemption per c. 152, $ l(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.] l 4 AY Phone #:-a*-31k-3>;4- Bu-sinq5s Type (r€quired): 5. ffnerail 6. ! RestauranttBar/Eating Establishment 7. E Office and/or Sales (incl. real estate, auto, etc.) 8. 9. 10. t 1. 12. Non-profit Entertainment Manufacturing Health Care Other .Any applicanr that checks box #l must also lill out lhe section below showing their workers' compensation policy information-.*lf the corporare omcers have exempted themselves, but the corporalion has olher employees. a,rorkers' compensation policy is required and such an organization should check box #1. I am an employer that is p Insurance Company Name rovl ,1 'ran(e empkryee s. Bel,is the policy informotion. e- lnsurer's Address tD4 ul<--' City/State/Zip Polcy # or Self-ins. Lic. #Expiration Date Attach a copl of the workers' compensation policy declaration page (showing the policy number and xpiration date). Failure ro secure coverage as required under S 25A of MGL c. I 52 can lead to the imposition 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 a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vcrification. n I do hercby ture Phone , under d pendties oI peiury thst the information provided above s lrue snd rrect. Date 5[ Selectmen's Ofiice 6. Eoth€r Permit/License # Phone #:Contact Person: 3E City/Town clerk 4.ElLicensing Board use onll'. Do not n'ile in t'his area, lo be compleled by ciy or town oflicial City or Town: lssuing Authority (check one): lflBoard of Health 2.E Building Department wu,w.mass.gov/dia 6- Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this stai)le, an employee is defined as "...every person in the service ofanother under any contract ofhire, 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 trustec ofan individual, partnership, association or other legal 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 thc grounds or building appurtenant thereto shall not bccause of such employment be deemed to be an employer." MGL chapter 152, $25C(6) als<l states that "everv 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 commonwealth for any applicant who has not produced 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 cnter into any contract for the pcrformance ofpublic work until acceptable cvidcncc ofcompliance with thc insurance reqiiircirrcnts cithis chaptsr huvc bccn prcscntcd to lhc r:i,r:tiucting luthr:i:ty." .4.pplicrnts Please fill out the workers' compensation affrdavit completely, by checking lhe 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 Partncrships (LLP) with no cmployees other than the members or partners, are not required to carry workers' compensation insurance. lfan 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 alndavit. The affidavit should be retumed 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 catl the Department at the number listed below. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that thc affidavit is complcte and printed lcgibly. The Department has provided a space at the bottom ofthe affidavit for you to fifl out in the event thc Officc ol Investigations has to contact you regarding the applicant. Please be sure to fill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/liccnsc applications in any given year, need only submit one affidavit indicating cunent policy information (if necessary). A copy of the affrdavit that has been o{Iicially stamped or marked by the city or tou,n mav he provided to the aoplicant as proofthat a valid affidavit is on file for fuhrre perrnits or licenscs. A nerv affi.,lllvit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not relaled to any business or comnlercial venturc (i.c. a dog license or pennit to bum leavcs etc.) said person is NOT rcquired to complete this affidavit. The office of Investigations 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 Office of Investigations Lafayete City Center 2 Avenue de Lafayette, Boston, MA 021 1 I -1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 Form Reviscd 712019 WWW.maSS.gOV/dia