HomeMy WebLinkAboutApplication and WC� ��7-oo3�aot�S�r�f?-O6? ����� __,�.� �. ��
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°� �` TOWN OF YARMOU N0V °92o11
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1146 ROUTE 28,SOUTH YARMOUTH,MASSACHLTSETTS 02664-2 �
'�•s'' Telephone(508)398-2231,ext. 1241 �'�al �
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Fax(508)760-3472 r_�
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SUN TANNING ESTABLISHMEN
�1� APPLICATION FOR LICENSE/PERMI -2018
,/a� Name of Establishment: ��I(�.Yl(�.�Gt.Y1 � ��a v`-e�L'�ax ID IN or SSN): �^
Address: o��J� ��'►1�'e� �(�'Tl'I , S, yarmc�t�, 'N� oa�t�y
Telephone No.: ��- �J q�-u��7 E-mail•
Mailing Address(If different from above): 3/�' ' � �l-av'�- �(2 ' p Ly���-�j ./VV� �U Z 3(�C�
Owner/Corporation Name: � � S I� 1'� • �.��� 1����lL Telephone No.: �g(r� �31 �S�. �3
Owner/Corporation Address: �u.►��
Manager's Name:_� �rS G� �d�-b�CX��L Telephone No.: �xs(a C�� �� I�
Manager's Address: S�a►'v►�—
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�davit
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 REQUIRED:
Fee: $55.00 per device
#OF TANNING BEDS:� #OF OTHER TANNING DEVICES TOTAL�ZZO�
TANNING DEVICE INFORMATION:
Manufacturer Model Number Serial Number Tvt�e of Bulb
o S�IY�--- r0 CV 5 � (�p
Notice:
PERMITS RiJN 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) e received. A hearing before the Board of Health
may be required prior to reopening.
DATE: � I `" � `�� SIGNATURE: ��"�'�'
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The Commonwealth of Massachusetls °�
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' CompensaNan Insurance Affidavit: General Businesses
Apulicant Information Please Print Le�iblv
Business/Organiza.tion Name: ���Qn d�
Address: `�3� ���1�'�j PQ-�
City/State/Zip: 5' . � U �,(,�(p�Phone#: �S-39 �-I- �-I�-I U 7
Are you an employer?Check the appropriate box: Business Type(reqnired):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑RestaurantlBar/EatingEstablishment
2.❑ I asn a sole proprietor or partnership and have no 7, �Office and/or Sales(incl.real estate,auto,etc.)
employees working far me in any capacity.
�No workers'comp.insurance required] g• ❑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.Q Manufacturing
no employees. [No workers'comp.ivsurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care
with no employees. [No workers'comp.insurance req.] 12.0 Okher
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensarion policy information.
**If the corporate officers have exempted ttremselves,but the corporation has other employees,a workers'compensation policy is required and such an
organizarion should check box#l.
I am an employer that is providing workers'compensation insurance for my employees. Below is the podicy information.
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 expiration 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 ce under the pains and penalties of perjury that the information provided above is true and conect
Si ature: �/�fi� VYt �� Date: � � � � � � �
Phone#: � � � — � 3 � � � ��
OfficiaZ use only. Do not write in this area,to be completed by city or town ofj`'tcial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Bailding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: P6one#:
www.mass.gov/dia