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' °� ` TOWN OF YARMOUT HEA�,��:
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= 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24�5'1" � �` �
� Health
"'°�'° Telephone(508)398-2231,ext. 1241 ; n� . ���i�,.��,�o./�
Fax(508)760-3472 � ° '-- �� ���' ��1�
SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT-2016
Name of Establishment: �'Qp� I GIVI Tax ID (FEIN or SSN):�
! Address: ��3� �r'U�1 I�C'S �Gt�l , S. yr,�v YYI o1it�'h MA �ZtDC.o�
Telephone No.: J`�- 3q y-y y�17 E-mail:�SIC1►1d�Z111111YLC.t C� Cc,�1M C('S��r�t
Mailing Address (If different from above):
___-- -- _ _ —_ ___- _ _ _
_ _ -- — - -:- -_ -----
�,-` __ _ _ _ _ __ __ _ _
Owner/Corporation Name: l�v�G��C� �C . Telephone No.:
Owner/Corporation Address:
Manager's Naxne: �Q Y?1 �1 �U[�C)Q..�f��'1 Telephone No.:
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 Compensa'on Insurance Affidavit
must be completed and signed.
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes �/ no
LICENSE/PERMIT REOUIRED:
i Fee: $55.00 per device
i #OF TANNING BEDS:� #OF OTHER TANNING DEVICES TOTAL �22-�•00
� TANNING DEVICE INFORMATION:
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Notice:
i PERMITS RUN ANNUALLY from January 1 to December 31. It is your responsibility to return the
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 reopening.
DATE: �2� i I I� SIGNATURE� ,��g����,� .
�ara�is
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�' . ; � Th e Commonwealth of Massach usetts
� Department of Industrial Accidents
Office of Investigations
` I Congress Street, Suite 100
_ Boston, MA 021I4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Auulicant Information Please Print Le�iblv
Business/OrganizationName:��j�Q�d �di'1
Address: �1Z�)�'11 kt'S �Q-�'1
City/State/Zip:�y�mpU-� IVl/-� 0?�n�� Phone#: �- 3q y-y u�7
Are you an employer? Check the appropriate boa: Business 1�pe(required):
i 1.❑ I am a employer with employees(full and/ 5. ❑Retail
' r art-time).* 6. Q RestaurantlBar/Eatin Esta.blishment
2. I am a so e pmpnetor or partners ip an ave no �, � Office and/or Sa1es(incl.real estate,auto,etc.)
� employees working far me in any capacrty.
[No workers' comp.insurance required] g• ❑Non-profit
3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.�Health Care
with no employees. [No workers' comp.insurance req.] 12.� Other
*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 '
organizafion should check box#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy infarmation. '
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the irnposition of criminal penalries of a
�`irie up to�I36�b�arid/or orie=year impnsonment,as we as Eivi penalties—m�fie" orm o a�fii�PtiP�1ZK�3RI)EK an�a-f'ine
of up to$250.00 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 insurance coverage v�rification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Si ature: �% GGll7�.l� Date: I Z�1�1 S
Phone#: ��- �Jq�-u u�� .
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia