HomeMy WebLinkAboutApplication and WC - ., P��N�- Fr,w�sr
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� � � °� ` � � ���TO WN � OF YA���RM��OUTH �� � � �
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= 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
�o �LTH DEPT. '
Telephone(508)398-2231,ext. 1241 ,
Fax(508)760-3472 "nG��n
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SUN TANNING ESTABLISHMENTS �- �-� _: �: .:,rs .: �
APPLICATION FOR LICENSE/PERMIT-2416
— . - blis�i�neat:-�-F-�4� -- - _
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Address: I� L-v�°�f_PoAC� Q�t'v�
Telephone No.: SOg�l�6 —�-36 U E-mail: �� (i Z20�� Cv/�CG.s�.he�'
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Mailing Address (If different from above):.36.� �as�h Po.s�- R�(. s��e ���, �vc�l v�y /�i,9' 417 7.� �
_ --—. __ _ _ _ _ — _ _ _
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Owner/Corporation Name: �� � _ ��� • Telephone No.: S`►!�`►�
Owner/Corporation Address: �
Manager's Name: �� 1�t� �d t�r Z Telephone No.: S!� � ;
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Manager's Address:
Under Chapter 152, Sec. 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 I
�ust tre completet�and�igne�. - -- --=—__ _ __. _�
--- -- — -- ___ �
Town of Yannouth taxes and li�must be paid prior to renewal or issuance of your permits. Please check ;
appropriately if paid: yes no i
{
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device
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#OF TANNING BEDS: 2 #OF OTHER TANNING DEVICES TOTAL � I(O.O O �
TANNING DEVICE INFORMATION: �
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- Mannfacturer lt�ad�ll��umber S�eri�Yi�'urub��` ____�'v��_�'�u�$___ _- -- _ j
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�Cq r�-�5tid T5�4� S✓`� k�L C!' L'.� .B 77� � V �
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NoNce: �
PERMITS RUN ANNUALLY from January 1 to December 31. It is your responsibility to return the f
completed application(s)and required fee(s)by December 31. Failure to do so will result in closure of your �
establishment until the required application(s)and fee(s)are received..A hearing before the Board of Health
may be required prior to reopemng.
DATE: � 1 L l f SIGNATURE: r
10/14/IS � . . � . . . � � �� � � . �
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` �� � The Commonwealth ofMassachusetts
_ Department oflndustrial Accidents
Office of Investigations
' ' 1 Congress Street,Suite I00
Boston,MA 02II4-2017 ;
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses '
Apnlicant Information Please Print Legiblv
Business/Organization Name: �G � �[. _� R,a- ��G�t t�- ��� �11
-- Address_ 1 Lv�,c, �a h c� �(c lrC _ �
� � _ _ i
City/State/Zip: _ �� �✓ Phone#: SU8 ,_., 7C Q -. �.�0 0
Are Y9u an employer? Check the appropriate bog: Business Type(required): ,;
1.�I am a employer with �6 employees(full and/ 5. ❑ Retail ;
___ __ _ --°���rt-time),*-- _ _ _ _ __ _ _. 6. ❑ Restaurant/Bar/EatingFstablishment - — - �
2.❑ I am a sole proprietor or partnership and have no �
7. ❑ Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑Non-profit �;
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment f
their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing �'
no employees. [No workers' comp.insurance required]* 1 LQ Health Care
4.❑ We are a non-profit organization,staffed by volunteers, r
with no employees. [No workers' comp. insurance req.] 12.�Other �c ?h P-f/ ��h�/`
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
or�anization should check box#1.
I am an employer that is prova ang workers'compensation insurance for my employees. Below is the policy information. I
Insurance Company Name: �'(�'1 �I'VS �- 1/�/ C S r C� �
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Insurer's Address: �� Sv D{r t tl r ,�v C�,v e. E . , 'et 1 J� F/o e r �
City/State/Zip: C( C ✓ e(��d . n 1-}' [�-l�. I � �.I- f
Policy#or Self-ins.Lic. #�j/ W L 3� .f� 3 �� Expiration Date:
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Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). ;
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the im�osition of criminal�enalties of�___ __ �
_ _ - - - --
fine up to$1,500.00 andlor 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 of this sta.tement may be forwarded to the Office of
Investigations of the DIA for insurance covera.ge verification.
I do hereby certi ,under the padns and penalties of perjury that the information provided above is true and correc� '
_ _. -----
Si ature: _ r{.I Date:_ . Z '
Phone#: � 3-• $3 �
Official use only. Do not write in this area,to be completed by city or town official
�
City or Town: PermitlLicense# �
Issuing Authority(circle one): ,d i
1.Soard of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board S. Selectmen's Office
6.Other
1
Contact Person• Phone#•
www.mass.gov/dia �'!
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