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°' ` TOWN OF YARMOUT 'l�`�`a��d���
� Health
t 146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 02664-2 H�LTH-DEP7'
�� Telephone(508)398-2231,ext. 1241 "_ � '�:altt� -� �.- �, .
Fax(508)760-3472 } �-` �`i iv;�ic�;ti `
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SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT-2017
Name of Establishment: t��A N� f t *� h�Jl Tax ID (FEIN or SSN)• �y'- ��� a 9 f 6
Address: I 1 L�O�1 q �o�d 0 ��� VC _
Telephone No.:�UQ— 76 0 -' �'3 0 0 E-mail: a� rr'22 0.SC7�C d✓ti C q1 -�. h��-
Mai ling Address(If different from above):�� QO.J�U h Qp,s�- �a(. S�}� �F��}, ,S'vG�6✓/•' �f} o 1776
Owner/Corporation Name: �G � f �'hL. Telephone No.:
Owner/Corporation Address:
Manager's Name: � �� ��' ���: L Telephone No.:.s��" �60�3�0 0
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 Insurarice. The attaehed State'6VVorker's Comg�nsatian Insurance Affi�avit
must be completed and signed.
Town of Yarmouth taxes and lie s must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes�no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device
#OF TANNING BEDS:� #OF OTHER TANNING DEVICES � TOTAL �
TANNING DEVICE INFORMATION:
Manufacturer Model Number Serial Number TvAe of Bulb
{-�eAr�I�►hd T�nh��. �v���,z21�� ,i^DOg077sS' (�I 1/
�' �� _ �'�2.�0��s'6
Notice:
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: d � SIGNATURE:
10/19/2016
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
' 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.»tass.gov/dia
Workers' Compensatian Insurance Affidavit: General Businesses
Anplicant Information Please Print Legiblv
Business/Organization Name: �G � . ��L .
Address: �1 �l� q P d h c� Q rr'�/�
City/State/Zip:S'�u r 1�10✓�'� � /��}- Phone #: .SJB-- �6Q — �-3 0 0
Are yQu an employer?Check t6e appropriate box: Business Type(required):
1.� I am a employer with�employees(full and/ 5• ❑ Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real esta.te,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance requiredJ 8� ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]* 11.[� Health Care
4.❑ We are a non-profit organization,staffed by volunteers, ,_.,/ � +_
with no employees. [No workers' comp. insurance req.] 12.LoJ Other 1�t� T VI GS� �N(/�
*Any applicant that chedcs 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
organi�ation sl ould chedc box#1. _
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name: I�/�'1 -�-�VS�}" �/✓�S C C�
Insurer's Address: 4(d0 ,S✓Q��� d Ir ��/�� G ,
City/State/Zip: �,� � �/e`q 1,o� d � �'y � �y-
olicy# r Self-ins.Lic.# W l�✓G 3�o�3��6 Expiration Date:
c 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 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 of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is hue and correct.
_ __ _ - -
_ _ ------ — ---_ - •
Si ature: /� . Date: � v � I�i - _
Phone#: r1��'' �3� ����
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):
i.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