HomeMy WebLinkAboutApplication and WC . 411- /boy►-s-Af-. 0-(z,---0-j-- 1 _V S(0
,,,,4""'""_ = TOWN OF YARMOUTH Board of
Health
lb1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-2445 . R LVED
'` Telephone(508)398-2231, ext. 1241 n;�ysiRyn,,
Fax(508)760-3472 Nuri 2018
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U HEALTH DEPT.
SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT -2019 p� p
Name of Establishment:CAC.Wilms"OTrWrr
SoatM wt+, Tax ID (FEIN or SSN): U2.-414(QI4
db., PIe cii+ s v
Address: r7 Low -Pena Or. SDut-IA 1 u Mtis
Telephone No.: SO "10O"'Z300 E-mail: C N1 On 12. V cii-eCtOtil cow'
Mailing Address (If different from above): I WO &rove SA-. Lh ki n M 1, 07..3&
Owner/Corporation Name: Di L Whelan AAy'TelephoneppNo.: x
Sb 412. ( (
Owner/Corporation Address: 1 (0(0 (70/Q, ck nhV IvAA07038
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Manager's Name: C t ` ` O n ( Z Telephone No.: Spit,`l(c0` ZYD
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 Compensation Insurance Affidavit
must be completed and signed.
Town of Yarmouth taxes and li s must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes V no
LICENSE/PERMIT REQUIRED:
Fee: $55.00 per device = $110 . 0 0
#OF TANNING BEDS: #OF OTHER TANNING DEVICES TOTAL 2 Uk1(15
TANNING DEVICE INFORMATION: Pea_ s AQP
Manufacturer Model Number Serial Number Type of Bulb
S110 DotZ2Ne'r SD-410-Vvot. St O 'O434o Cosm , lbow, g.i I ,VAR
Su Qot221-Zi( SO-4(0-VW‹ SOOeib1-05 COSMI t6OWi MI i Vi'g-
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 rec-'ved. A hearing before the Board of Health
may be required prior to reopening. iIA
DATE: II 1(d
DSIGNATURE: .�►
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017.
.r_ ,,yz0,7 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 1► (' 0 AL �� % � i. RAte5,5
Address: gob
City/State/Zip: VickftW tOs 0z(53 g Phone #: 51%
Are you an employer?Check the appropriate box: Busin Type(required):
1.Wr I am a employer with S employees(full and/ 5. LJ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
8. Non-profit
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised 9. 0 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.] 12.0 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
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: ` eChnoSOCIi Tr1SMitleW 60 b4 Zfl
Insurer's Address: ?A) Tilt' j t o In GAL Su(4{, 4
City/State/Zip: Nash t'- 03063
Policy#or Self-ins.Lic.# 111\k" 302.082- Expiration Date: 4-IID'f
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 certi ,un'' he pains and penalties of perjury that the information provided above is true and correct.
Signature: .�� Date:
Ill t4 ig
Phone#: '/• 114-6'35-Mil
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