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Home My WebLink AboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $165.00 Sun Tanning Establishments License Number: BOHST-21-2810 Issue Date: Mailing Address: Location Address: KERRIE KIRBY 23D WHITES PATH UNIT 19 ISLAND TAN & WELLNESS SOUTH YARMOUTH, MA 02664 23 WHITES PATH SUITE D SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge , Health Eric Weston / I/ � ruce G. Murphy, MPH, R.•.,SHO/Mallory R. Langley, R.S. Health Director/Assistant Health Director 0 o ..._Y. -. TOWN OF YARMOUTH �� 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Telephone(508)398-2231,ext. 1241 Board of Health Fax(508)760-3472 P] Health D Division SUN TANNING ESTABLISHMENTS APPLICATION FOR LICENSE/PERMIT-20: ll y� 4. All es5 t Name of Establishment.-. S-.L !i ofLi Q-� Tax ID(F or SSN): "R 5 _a b S o a t 6 Address 3 W •L�.5 /_a h 50_ . _)__ S jla r rri o okl 7 a Oa WP Li .508..,'qy- L1q 7. c.�C c, _. . �'S l arl ,'rL 304(.1 .60 Telephone No.: E-mail: /17 Mailing Address(If different from above): Owner/Corporation Name::-* - land . .l 4 i e 7 _ Telephone No.: 450 8-3 TY•4/V` 7 Owner/Corporation Address:-.(5. ""` 't LS Path c. V f r p / 7 Manager's gcr I C� jG' �J �/ f Name: �� Telephone No..:-� Manager's Address: 0.6 01141e- 3111,..S W Q. 5� t- en ,S, n9'1 O S h O r 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 liens m be paid prior to renewal or issuance of your permits. Please check appropriately if paid:yes V no I LICENSE/PERMIT REQUIRED: ,A i 06 1021 \` Fee: $55.00 per device #OF TANNING BEDS: #OF OTHER TANNING DEVICES TOTAL TANNING DEVICE INFORMATION: Manufacturer Model Number Serial Number Type of Bulb eOy al sort 38/0A 3`'JD7/ u all. 160 PoidaP) d a l 5 aq 3 Da 35007a u� 111 a Ca Land yn 1 *Jaz 3w7 65'007u ill_ - ( aL sort beet) 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: I q/C1101(,) SIGNATURE: AA izt j 11/05/2019 The Commonwealth of Massachusetts Print Form , -""- Department of Industrial Accidents =7.21,_=== l Office of Investigations 1 Congress Street,Suite 100 •,, __ Boston,MA 02114-2017 r,�•s`� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Is 1 an d Ta') '' Address: 013 W/l 6 CL S iQ L h JOI u D City/State/Zip:i. 'O( (fWi , 177a 4,Aone#: 508-59 Li" LP-1117 Ar_e_np an employer?Check the appropriate box: Business Type(required): 1.I� I am a employer with employees(fu11 and/ 5. EKetail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Saks(incl.real estate,auto,etc.) employees working for me in any capacity. 8. El 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]** l i. ealth 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 til. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy in rmation. Insurance Company Name: Atnietdd *" CGv'I�5pn motif-at 43ency hi PI mot L Insurer's Address: T•0 .3b X 719 Soncitilic.h , 771a Q a 5 City/State/Zip: ` t� Policy#or Self-ins.Lic.# V ►A/J 100"46 7•41(1,;(3,- 0X) Expiration Date: 5//7 gOt/ Attach a copy of the workers'compensation policy declaration page(showing the policy number an 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 ify,under the pai and penalties of perjury that the information provided above is true and correct. Signature: Date: /9/111 a O Phone#: 5b -3Q L- sfq4 7 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 NOTICE :( 4 , R, NOTICE TO TO EMPLOYEES f ' O ES \ . EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, &30,this will give you notice that I(we)have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-6024022-2020A 05/17/2020- 05/17/2021 POLICY NUMBER EFFECTIVE DATES PO Box 719 Almeida &Carlson Insurance Agency Sandwich, MA 02563 (508)888-0207 NAME OF INSURANCE AGENT ADDRESS PHONE ISLAND TAN &WELLNESS 23 WHITES PATH SUITE D SOUTH YARMOUTH, MA 02664 EMPLOYER ADDRESS 06/11/2020 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 11:02 A4 Wed Dec 30 ^79%L*D h iii oregon.gov Effective Dilutable Disinfectants to Help Fight Novel Coronavirus Disease(COVID-19) To be effective,disinfectants must be left on surfaces for a specific length of time(contact time).and concentrates(dilutables)must be diluted according to label directions.The required contact time and dilution are specific to each disinfectant and each virus to be controlled and are provided on the disinfectant product label.Reminder:Some products are Ready-to-Use (RTU)sprays or wipes and do not need to be diluted with water. There are no disinfectant product labels that currently list the virus that causes COVID-19.However,the US.Environmental Protection Agency(EPA)has pre-approved certain products that are effective against similar viruses.All disinfectant products on this list meet this standard.However,use instructions,including use sites,on physical product labels can vary.Please check and follow the physical product labeling prior to use Alert:There are some product labels that list"human coronavirus'Depending on the label the directions for use for-human coronavirus'may not always meet EPA's high standards for emerging pathogens,such as the novel coronavirus that causes COVID-19.However,you can ensure maximum virus-killing power through one of the following methods. Ensuring Effective DishHectant Use: Option 1:Look for the"Disinfection"section on the label and use the maximum contact time and most concentrated dilution rate(largest amount of disinfectant to mix with water)that is listed in this section. Option 2:If you are unsure about the contact time or proper dilution.contact the product manufacturer for assistance.Technical sheets describing effective use may also be available from the manufacturer. Important:Read and follow all safety precautions and restrictions on disinfectant labels,paying special attention to the First Aid section.Do not use measuring tools that are used to prepare food. do SP t•L G, L 5 grade_ V i S i rl.`1 C,UanL ()tie_ vse `Z' haV/e- i n d J d Ldl all ±h!-- Pawl;V1` Ieared3 25/2020 IS � �,r�cr ��j San , 10I- - � C U/� a1Sd �Se. er i Pracuct Norge :EPR Reg, F s Product Type _Follow t se divrdeeritlr: I Contact'ante' 1 Dilution Rate." c:i t _ labe" direction for-2.... i # 1_ �tlsaaimany mirridrs iimxect+ssrfiuizSc�rra:,t-s 1 i to surfaces Wet 1 pr.,'nation unless i withdksmnfectantl i otherwise rested) i i i. 2 XL CORPORATION COifend Disinfecting Tablets 11947-6.82144 Dilutable Hepatitis A eras. 1 4306 ppm Coxsackievirus B3 2. 3M COM ANY 3M Non-Acid Disinfectant Bathroom Cleaner Cone 1839-166-10350 Dilatable Human Coronavirus 10 1 3. 3M COMPANY 3M HB Quat Disinfectant Cleaner Concentrate 61178-5-10350 Dilutable Human Coronavirus 10 0.35 4, 3M COMPANY 3M C.Diff Solution Tablets 71847.6-10350 Mutable Hepatitis A virus: 1 4306 ppm Coxsackievuus83 5. AFFLINI[LLC Afflink Member Brands Affex Cleaning Solutions 70271-13-88891 Dilutable Human Coronavirus 5 6 Germicidal Ultra Bleach _ 6. AIRKEM PROFESSION Ecolab HB Qual 61178.1-42964 Deutable Human Coronavirus 10 2 PRODUCT 7. ALEX C FERGUSSON LLC Quat 20 10324-94-833 Ddutable Human Coronavirus 10 0.4 8. ALEX C FERGUSSON LLC Lemon Velvet 1839-168.833 Dilutable Human Coronavirus 10 4 , 9. ALEX C FERGUSSON LLC _Vigil-Quat 6836-70-833 Dilatable Moran/us 10 0.77 10. AMREP INC Misty Biodet N032-Lemon 47371-192- (Mutable Adenovirus 10 16 10807 1 i. AMREP INC Misty Biodet NO32-Pine 47371-192- Dilutable Adenovirus 10 16 10807 12. ANABEC INC Anasphere Plus 61178-1-72786 Dilutable Human Coronavirus 10 2 13. ANDERSON CHEMKAL Laundry San 10324-117.1SO Dilutable Human Coronavirus 10 0.6 COMPANY 14. ANDERSON CHEMICAL BARRIER II 1839.86.150 Dikrtable Human Coronavirus 10 0.7 COMPANY 15- ANDERSON CHEMICAL Defend 1839-95-150 Difutable Human Coronavirus 10 2 COMPANY 16. AQUACHEMPACSLLC Disinfectant Cleaner 1839-176-88326 Dilutable HumanCoronavxus 10 1552 ppm 17. ARJOHUNTLEIGHT INC Cen-kleen N Cleaner/One-Step Disinfectant 6836.75-45556 Dilutable Norovirus 10 8 18. AUSTRALIAN GOLD LLC Australian Gold pH Neutral Disinfectant Sanitim 47371-131- Dilutable Adenovirus 10 8 61617 19. AUTO-CHLOR SYSTEM Auto-Chlor System Roomsense 200 Disinfectant 1839-1666243 (Mutable Human Coronavirus 10 1 Cleaner Page 2 I Created 3/25'2020 Nat`• • . Manufactureri Product Res the disinfection tion Contact There' t2illtilan idiot Drstr ar ' (abelingdirection for:' )(hocir many £ ounces to keep wet I per gallon ---,- !with r re rt 20- AUTO-CHLOR SYSTEM Auto-Chlor System Solution QA Ultra Sanitizer 1839.866243 Dilutable Human Coronavirus 10 0.7 21. AUTO-CHLOR SYSTEM DC 33 I839-95 6243 t lttabfe Human Cownavrrus 10 2 22. BAD AXE PRODUCTS LLC ONSLAUGHT 61178-1-88903 D4uIable Human Coronavirus 10 2 - 23. BASF CORP Green-Shield B Disinfectant 10324-94-7969 Dilutable Human Coronavirus 10 04 .., . 1 , A i /11 , I ' : : '•. - left -.,' %., f ' i ' • • . , • i lig4 : f, I' /' 1 '' i 4 .• 1 1= il 4 1- . 4 1 t 1 I t I 1 1 IS :1 1 i44. !o. i I i li , * 4 g , •!. I!ir ; i . * I . li ji ' 4 111 ! it. i, i t.r• r according the AOAC Use-deubvn Test Orcrr'►?ctsdein; and deodorizes in cn 4bor•saysna slep rot I drurrtiect.ere _+t send colt9es unr.ervdes, commercial arid rie-.41rui rnstriuhons. office burkfrr s, 'ares, ash oeodoeizts 4:4 - •_ "owwe. , rior►otlrousm otanim i3! betteces floors. galls; metal surtxes. st nlesi trta:ns ,s r', + as Po,p►oc One po -,• •mireacrjicc etc ) crytdx'xcss aurlv$1. S: x:0414 irtir.:a. krse'1oba:ter Laicoocstcus. Badetina bronctistOca. cP4amyda r*"j Assocu0ed MeltsCat n • Retsistart cCA-MPSA) (kR$3$4) (USA30O . S aphglocaccus awevs - Corrunw ty RSA) l%RS123 (USAi001, Enterobacter arc/ones, Erterobacter cloacae - UDM-1, Enlerococcus !mulls - Cob• k t•1. ksceaclerrum rignrophorurn Kletniella crw rnvrrai• light t lvornra prrturnophta. 1rs rri 'rotates mirablit Prete et vkicarti, S.ermonetla en1crnbdis Satmor'�e rot' Sir rr,3rlr14 tvptrmurwm, Se-rx:u Irset Staphylococcus&epos-P.Ifeenocitio Resister/',MRSA t. St ipfy o occur AV a tS • Vocoirtion IrClarrredu't i642.SirsOKOC s>l+A boak$1 .StnrPtIxcccuc PicSaiss(Strep! 1 ATCC 4 ar '.+C-res4stant ate►2 antibiotic. s ';:M l . at 8 OZ t plat ' itrt*s Virus ("1 'f+erp4s 5 r qs V�rvs e : c*'r•+ 'Mtn 1 (AIDS rirusl, 'Whew.A Woes i nq i . q, `Rcr irv�►us (WA) •Rrspiraf ry Syncytial C a'td CortxtJwtts. '1htono (Pm Virus). 'Ait.in pciyonvatus. 'Equine Herpes Wus Typs 1. *InfoClka.s EaOv+M rt►rictrachabs. "lniscbcils t'onc i(rs e p.owoorus. 'Pse oorables ,PRY}. 'A.tb.es 'Ttanynesisree Garstrcet+terits wus (TGE). 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