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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal of
any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation
Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE
COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1�
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES V NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
77 3 a'M,cF'iI I 171 1.:121 MIA
A1111111111 :. II %" !.; lii' i as, I to !" "•
1,}' ".s'- _..; I.7'�%. "€;1"','t:813 i.1:.1f.. 1;9 !'. t! li i►:E ri. :+I ice' 1111 W. / /" • f
1"1
;: �7 : '1T,. �' 1 1'1.":3 1;" 1'". t. "'w�la I"s' .f .IIIc. 1 111 f1 . Ii !.' :. i � ' / . il! " 1 / 1 • 1 • . 1 . • "
' be by a S� coed lab prior to opening and monthly thereafter, with sample results
`rt lofhe l&—,MDeparhnenL Fad tD do so will result m the suspension or revocation of your Frozen Dessert
PcngitunO the above ums have bem meL
HSE CAFES:
Outside cafes (i.e., outdoor seating with waitedv itress ser -vice), must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPI�'T, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
C0N%4ENCEMIEN - RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: 0�/Zt 41 SIGNATURE:
PRINT NAME & TITLE:
Rev. 10/08/13
a
Tke Conv�wnn+ealtk ofMassachusetts
� Depnrtment ojlndrest►ial Accidentt
OJ�ce oflnvestigattorts _ .____ _ -_._.-------
1 Congress Stred,Suite I00
Boston,MA 0211�2017
www.nwss.gov/dia
Workers' Compensation Insarance Affidavit: General Bnsmesses
A licant Informatioa PI e ' t
Business/Organization Name: �}ss I v�A- �[-�(i
Address: . � �°X /�'✓ M�'1� vr Fh�►�/clir.y P 1�r4c� �-J
��
CitylState/Zip:�O�� �a�'�1IF �� Phone#: ��- ��P - `�7`�
Are yoa aa empbyer?Check the appropriste boz �m�TYPe<��)�
1.�I em a employer with�employces(full and/ 5. �Retail
�P�-�e)•' 6. ❑RestawaatBat/Eating Estsblishm�t
2.❑ I am a sola propriaor or eaship and have no �- ❑Office and/or Sales(incl.real esau,auto>�c.)
employecs worldng for me in any c�pacity. 8. �Non-profit
[No workers' comp.ms�ance r�uired]
3.❑ We are a coiporation and its officers have exa�cised 9. Entertainmcat
the'v right of exemption per a 152, §I(4),md we have ip,�Manu�cd�ing
no employces.[No workers'comp.rosmance required]' 11.❑Health
4.❑ We are a non-pro5t organi�tion,staffed by volimtcers, f� �
with no employees.[No workas'comp.insmance req.) 12. Other�LaNS wr77�- JNa4E-
'Auy appGcmt t�t c6aks box kl must also 511 om the axtion beba showing t6e'v worke`s'compenss5on policy infortmtioa
••If tL¢�pocm offica[s 6sve ex�pud ihevmehres,but the capauion)rs otLs e�luYas.a workas'wmpense[ion policy is rary'vW and such m
� organiationshouldcheckbox#1.
I mn mt a�ployer Nwt B pmvf�g wor�ters•��� r�►��.�p�*a��+�so��
Insurance Company Name: 6 �l1�/ d 6 NJ�IRw+�rcE ���'�7
Insura's Address: �`r �4wT'M�Y lAEW A9 t y1�MfA+ /V J D�a(.o
CityJStffie/Zip:
Policy#or Self ins Lic # �� `���3 � �3 -/� E�miration Date: �./yf��
Attach a copy of t6e workers'compensatios polky declantba page(s6owing 1Le pol�y nam6 snd irttiou data�
Faihme w seciue covaage aa requ'ved�mder Secrion 25A of MGL c. 152 c�lead w ihe imposi6on of crnnroal pmaifies of a
fine up to 51,508.00 a�l/or onayear imprisonm�t,as well as civil penalties in the fmm of a STOP WORK ORDER and a fine
of up w 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for ins�uancx coverage veriScation.
1 do hereby cernify,unAer RurP��P�^���IPQ.lui1'that the infornmtion provFded above ic Lrrre m�d corrrer�
�:� �. • oe � l�l r� r�cse�'a�R. vsre• (��o �or3
Phone*. ����N -71��
OJ)3da1 use only. Do not wrlte in this area,to be comp[eted by city or town o,�'icia[
City or Tmvn: �/�}kJk0�3S PF Permft/Lkense#
'rck one):
.Board of Heslch Build'mg Departmeut 3.City/Town Clerk 4.Liceosing Board 5.Seteetmen's O�ce
6.
ContaMPerson• Phone#: rS�B-��R-a�3( Xl2`(I
�� www.mass.govlaia