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HomeMy WebLinkAboutApplication and WC ` -r�qi,c..��,� fZ�1�J+3J� r 5�. t�N -�-- ���-bb 2 g� r�-, � „� � U'` „LJ�� J . � O.J/O�V� �'I��/w`i Z �L� P,�� ! �Q�� � °� TCJWN QF � ARMOUT HE� r ��r 1146 ROUTE 28,S�UTH YAItMOITTH,MASSACHUSETTS 02664-2,�1 n� " �� Telephone(548)398-2231,ext 1241 .� ' r � ���' ' ;�- Fax(508)?60 34�2 ���� � ' � C.�C:���`�" SUN TANNIl�TG ESTABLISHMENTS APPLICATION FOR LICENSE/PERMIT- 8��b��1�I Name af Establishment. ..�-LS��i'1C1 �Q V] Tax ID(FEIN or SSI�: � � L�" Address: .�3� �`���11��5 Gt�f r i , CJ. ��y rn au+h.r, 1\/� C�Zr�ata� Telephone No.: �- 39�-I-�1��I 7 E-mail_y�SI(�►'iCI�ZI n Yi i YtLC La t�.SYt9 C�5 t..r�t Maili�ng Address(If different from above): OwnerlCorpvration Name: ���CkC1c_ �Y1C . Telephone No.: C�vner/Corporation Address: Manager's Name: �a Yr�t � i�l r)t�v0.,�i��'t 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 orp t to operate a business if a pesson or company does not have a certific�te of Worker's Compensation I��ce. The attached State Worker's Compensation Insurance Affidavit must be completed and signed. Town of Yazmouth t�es and lie�s mus�be paid prior to renewal or issuance of your permits. Piease check appropriately if paid:yes ✓ no LICENSE/PERMIT REOUIRED• Fee: $SS.UO per device #OF TANNING BEDS:� #OF UTHER TANNING DEVICES TOTAL �220'�� TANNING DEVICE INFORMATION: --Manufacturer -- - 1VIode1 Number - Serial l\Tumber Type of Bnlb r 1 UUG�a �.1Y1 1"C�L�)� � 12.2t�t`� . ���-- Notice: . PERMITS RIJN ANNLJALLY from January 1 to December 31. It is your responsibility to retum 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 heazing before the Board of Health may be required prior to reapenuig. • � DATE: I 2.�1�.��� SIGNATUREz ��.� , Q .�.,��� ta�ais .. �� . . L/i{i VV/�Miw.����vw���� ✓ �.����'__________ _ �; Departrnent of Industrial Acridents ' �, Office of�nvestigations `� � I Congress,Stree�Suite I04 ''� Boston,MA 02I14-20I7. www mas�gov/dia Workers' Compensation Insnrance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: ��ICZY�d ��t i�t � AaareSS: ��t��i k-�s �a-�t City/Sta.te/Zip:� YYYi�Ill 11/VVI t52.�n�o� Phone#: �- 3q�-���7 Are yon an employer?Check the appropriate bog: Bnsine�T3'Pe(reqnired)= l.❑ I am a empioyer with employees{full and/ 5. ❑RetaiJ. or part time).* 6. ❑RestaurantrBaz/Eating F.stablishmern � _ _- -_ ---- -- - --- 2. I am a sole ro efor or ershi and have no -- � -- - P lm P� P 7. ❑ Office and/or Sales(incl.rea1 estat�e,auto,etc.} employee,s worlQng for me in any capacity. [No workers'comp.insurance requiredj 8. ❑Non-profit 3.❑ We are a corporation and its offcers have exeraised 9• ❑Entertainment their right of exemption per c. 152, §1(4�and we have 1 p.0����ng no employees.jNo warkers' comp.insurance required]* 11.�Health Caze . 4.❑ We are a non-profit organizaiion,staffed by volunteers, with no employees.[No workers' comp.in�r�ce req.j 12.[+�Other "�Y aPPlic�nt that checks baoc#i must al�fill otrt the s�ti�below s�owing Lhefr worloers'compens�ion Po1icY mfarm�ian. ::If the ooiporate officers have e�cempted themselves,birt the oorporaiion has othca emploY�,a��'���P��T is req�ured and snch ffi or�aization should chedc box#1. I am on employer that is providing workers'compensation insurance for my emploYee� Below is the policy ixformafion. 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 palicy nnmber and ezpiratioa date� Fail�.u�e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of eriminal penalties of a � fine up to�I;5Q0.�or one-year imprisonment;as well as civ�-rcnaZ�e§in�e form ofa STt�P WaRK OKDER an�"a�ne - of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of Tnvestigations of the DIA for insurdnce coverage verification. I do hereby certify,under the pains andpenaliies o.fP�.7�'1'that the information provided above is true and correc� Sig�ature- �����IK�JC Date• � �I1� ��o Phone#• ��� �J9�-���d7 . — O,fficial use only. Do not wrife in this area,to be comp[eted by city or town officfaL City or Town: Permit/I�icense# Issning Authority(cireie one): 1.Board of Health 2.Bnilding Department 3.Cify/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Qther Contact Person: Phone#: www.mass.gov/dia