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Home My WebLink About2025-26(h Ne //4/6 ,anvE-r,LTCENSE FEE srso &lHM - ?J -g+3 , -. 0 7 20i5 rdrrvx oF yARMourH BoARD oF HEALTH 2025/2026 HANDT-tlb alo sronLcE oF Toxtc oR HAzARDous MATERTALS 1ALTH OE ' - -l LICENSE APPLICATION COMPLETE THIS APPLICATION AND Rf,TURN IT WITH THE LICENSE FEE BY JUNE 30. 2025 508-398-2285 PLEASE COMPLETE ALL OI]ESTIONS NAME OF IIUSINESS Hallett Funeral l{ome Inc.BUSINESS TEL. # 273 statlon Avenue, South Yarnouth, MA 02664BUSINESS ADDRESS IN YARMOUTH MAILING ADDRESS same EMAIL ADDRESS 1nfo.aha11ett funeralhome , com BEQIJ.IEq MANAGER/CONTACT PERSON TELEPHONE# 508-398-2285 Falth A. Hallett BEQJJIBED OWNER NAME Falth A. Hallett HOME ADDRESS 2 Eln Street, Dennls, l4A 02638 TEL.# 508-398-2 285 CORPORATION NAME (IF APPLICABLE) SANC CORPORATION ADDRESS sam' MAILING ADDRESS SAIDC 1Ey. s sO8-398-2285 TAX ID (FEIN OR SSN)REOUIRED 04-2427 7 58 LICENSES RLTN ANNUALLY FROM JULY I TO JUNE ]0. 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 LTNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEN'ED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check annrooriatelv ifoaid: ves XX no na Under Chapter 152, Sec, 25C. subsection 6, the Town ofYarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa pcrson 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 Compcns ation Affidavit. If not applicablc, please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED XY . YN AI,I, SAFETY DATA SHEETS ON FILE YYyN ANYNEwCHEMICALSMUSTBEPRE-APPROVEDBYTHEHEALTHDEPARTMENT. RENEWAL APPLICATION n( NEW APPLICATION- APPLICANT'S SIGNAT DATE q, - The Commonwealth of Massachusetts Depa rtm e nt of I n du strial A cciden ts Offi ce of I nvestigatio n s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021 I I-1750 www.nass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name: Address: HaLlett Funeral Home Inc. 273 Statlon Ave. CitylSratelZip:South Yarmouth, MA 02664 Phone #: 508- Are you an employer? Check the appropriate bor: t. EI I am a employer with 7 employees (full and/ or part-time ). * Z. n I am a sole proprietor or pannership and have no employees 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 employees. [No workers'comp. insurance required]** 4. ! We are a non-profit organization, staffed by voluntecrs, with no employees. [No workers' comp. insurance req.]tz.E other Funeral HoBe *Any applicant that checks box #l must also fill oul the section below showing their workers' compensation policy informatio[.trlfthe corporate offrcers have exempted themselves, but the corporation has other employe€s, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Name The llart ford Policy # or Self-ins. Lic. # 08 WEC AY2LPK Expiration Date 7l17 12025 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to sccure coveragc as required under $ 25A of MGL c. 152 can lead to the imposition ofcrirninal penaltics 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains lnd penalties of perjurr- that the information provided above is true snd correcl Sisnature Dolc Phone #: 508-398-2 285 Official use onty. Do not b'rile in lhis area, to be compleled by city or town ollicial Permit/License # Phone #:Contact P€rson: 3.E City/Town Clerk 4.ELicensing Board Citr or Town: lssuing Authority (check one): lflBoard of Health 2.8 Building Department 5[ Selectmen's Office 6. flother www.mass.gov/dia Business Type (required): 5. I Retail 6. E RestauranLtsar/Eating Establishment ;. I Omce and./or Sales (inc[. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment 10.! Manufacturing I I .! Health Care Insurer's A<ldress: 3600 Wlsernan B1vd. , San Antonlo, IX 78251 CirylSratelzip: Information and Instructions An employer is detined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in ajoint enterpdse. and including the legal representatives ofa 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 of the 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 bc deemed to be an employer." MGl" chapter 152, $25C(6) also states that "every state or local licensing agency shall withhold the issuance or rencwal of a licensc or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced ecceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, S25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for lhe pcrformance of public work until acccptable cvidence of compliancc with the insurance requirements of this chaptr:r ha,,e bec-n prescnted to the contract'ing i:rtthoritr." Applicants Please hll out the workers' compensation aflidavit 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 Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. lf an 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 affidavit. Thc 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 call the Departmenl at thc number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be su.e that the affidavit is complete and printed lcgibly. The Departmcnt has provided a space at the bottom ofthe alfidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/liccnse applications in any given year, need only submit one aflidavit 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 applicant as proofthat a valid affidavit is on file for firhrre permits or licenses. A new affrCavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.c. a dog license or permit to bum leavcs etc.) said person is NOT required to complete this affidavit. The Office of lnvestigations 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 Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA02lll-1750 Tel. (857) 321-7406 or t-877-MASSAFE Fax (617) 727-7749 Form Revised 7/2ol s WWW.maSS.gOv/dia Massachusetts General Laws chapter 152 rcquires 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." THE THE HARTFORD BUSINESS SERVICE CENTER 36OO WISEMAN BLVD HARTFORD SAN ANTONIO TX78251 AB 05 000094 67310 E 2 B il,trtltl,l,iltl,[ilt,,1,,,,ilil1,lhil,,hrltrlll,r,,ltrlillI tr HALLETT FUNERAL HOI\4E INC 273 STATION AVE SOUTH YARMOUTH M 402664.1842 June 7 , 2025 Policy lnformation: Contact Us Policy Number:08 WEC AYzLPK Renewal Date:07 t17125 Visit https://business.thehartford.com 2417 access to pay bills, view policy documents, get your certificate of insurance and more. Need Help? Chat online or call us at (866) 467- 8730. We're here Monday - Friday. Dear Policyholder, Thanks for being a loyal customer of The Hartford! Your workers' compensation policy is scheduled to renew on 07117125. This packet has your renewal documents and other important info about your upcoming policy term. Your bill for the new policy term will come later, about 20 days before your renewal date What vou should do riqht now After that, you can look through the rest of the packet to make sure everything looks right. Here's what you'll Iind, in this order: Any documents required by your state Your Declarations page Billing information Any endorsements on your policy lnformation about your premium audit E scPHs017 Check the back of your packet. There may be posting notices to put up in the workplace, or forms that you'll need to sign and return if you haven't already.