HomeMy WebLinkAboutApplication and WC; #��7—o03%ao�S�r�-!?-O6? ����.� _�� _ __��
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NOV 0 9 2017
°� ` T O W N O F Y A R M O U Board of
� � �
= 1146 ROiTTE 28,SOUTH YARMOiJTH,MASSACHUSETTS 02664-2 '' ��
'0�'' Telephone(508)398-2231,ext. 1241 � � �al �
Fax(508)760-3472 �s'
�01� �-'���
SUN TANNING ESTABLISHMEN
,�,q APPLICATION FOR LICENSE/PERMI -2015
� Name of Establishment: ����(�.�Q� � ¢��a v'��ID IN or SSN)• � �
Address: a��J/ ��'1 l,�'�S �(,�� S, yarmo�� I� p a L��
Telephone No.: ��� 3 q�I-u u y 7 E-mail•
Mailing Address(If different from above}: 3/� -� �I,av'� D 12 • p Ly w�u:�'t�-E ,/V�A i U Z 3(�C�
Owner/Corporation Name: � � �I� 1'� � �.�� (����IL Telephone No.: �g(o tn3) ,��, �3
Owner/Corporation Address: �a r� .e_
Manager's Name:_ l�I�S C,� �o�-��CX�L� Telephone No.: �Xs(,(Q� �. 1�
Manager's Address: S'a m�--
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 opera.te 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 Twe of Bulb
�I�o� � _ �Oc,us '
�
Notice:
PERMTTS 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) e received. A hearing before the Board of Health
may be required prior to reopening.
DATE: � I " � ''I`� SIGNATURE: �rv" -
iomnoi�
,
1
� The Commonwealth of Massachusetts �;
Department of Industrial Accidents
Offace of Investigations
1 Congress Sheet,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensallon Insurance Affidavit: General Businesses
AnnGcant Information Please Print Le�iblv
Business/Organization Name: �j��(,� ��
.
, Address:__ ��J� �,��1��5 1'Q�
City/State/Zip: S' , � U Z.(.e(��Phone#: rj—bB-39 �- �-I��-I 7
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantlBarBating Establishment
2.❑ I am a sole proprietar or partnership and have no �, �Office and/or Sales(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 �
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers'comp.insurance required)* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
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 infortnation.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that u providing wo�kers'compensation insurance for my employees. Betow is the policy 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 thepains andpenalties ofperjury that the information provided above is true and correc�
Si ature: vt/Xn Wt �t Date: l � � �i —' � �
Phone#: � �3 � � C� 3 1 -' �`z- f�
Official use on[y. Do not write in this area,to be completed by city or town o,�cial
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