HomeMy WebLinkAboutApplication and WC ��� Chiidl�e�eic�'-xrt-
u TQW N t�F YARNIQtJTA BOARD OF HEALTH (� (� f� [� � �f (� �}
. � > APPLICATION FOR LICEIVSE/PERMYT- 1999 ��� Z 4 ��gg
* Please eomplete forrn and attach all necessary doqtmet�ts by Dtxemi�3I, 1998. F ' �..�t��s�,w�,�L�utt
the return of your application packet. � Q �,� �� �c j�� _, t /�j,y�� ,
D4
------------------------�----------'------- •^__-x ---"------"'--'_-�'^ -"--
A Qo h.���utlo ,-r�c,.7-�Rao- — 2 �ilA'
�G6rn s G/.� — GJ.
I � fi� 2 0
^r � C.f-f�G VCL�1 r
A R' a7 '�'7�-li��f0
r �
POOL CBRTIFICATIONS�~ �
The poal supervisor must be certified as a Pool Operator, as reqpired by new State law, Please fist the
designated Pool Operator(s) and attach a copy af the cert�Scation to ttus form.
1. 2�
Pool operaiors must list a nunimum af twoemp loyees�vrremly certified 'u►basic water safety, standard First Aid and
Community Cardio�ulmonazy Resuscitation(CPR). Please tist these eanplayees below and attach copies of employee
cerkifications to tlus farm. The Health Dtpartment wiU nat uee past qeara�' records. Yom m�st provide new
copies and maintain a iile at your place of bneiness. .
�. 2.
3. 4•
HEIMLICH C'ERTIFICATIONS•
All food service estab[ishments with 25 seats or mare must have at least one emplayee trained in the Iieimiich
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and
attach rApees af empioyee certifications ta ttus form. The He�it6 Deparkment w� oat nae past yesns'reeflrds.
Yoa muat pravide new capies and maintain a fde st your pl,ace af busineas.
1. 2-
3. 4•
RE5TAURANT SEATING: TOTAI..# NON-SMOKING SEATS: TOTAL#
____ _ OFFjCE USE ONL-Y ____________�_----
WDGI�yG. Y�
�, ,<
LICENSE REQtTIREi} FEE PERMIT# LICENSE REQUIREI? ,.P ' ��'�`0�o
o ena�rt $��'� , c,� ��,,
B&B $5 _
INN $Sd �„CAMP $50 �.J=�-�„
LODGE $50 TRAILER PARK S50
MOTEL $50 _SWTN�A�fINGP00L SSOea.
WklIIti.POOL $25ea.
FOOD SERVIt'E:
t,ICENSE REQUIRED FEE PERMIT# LICENSE REQCTIRED FEE PERMIT#
0-100 SEATS $75 CONfINEIVTAL S30 v��p
_}100 SEATS $15q TNON-PROFIT $25 _����
COMMON VICT. $54 _VYHOLESALE $75 '
RF.1'�S�'RV� ICE:
LICENSE REQUIlLED FEE PERMIT# LICEIVSE REQUIRED FEE PERMIT#
{50 sq.ft. $4S �TOBACCO S20
_{25,q00.sq.$. $75 FROZ�N DESSERT $25
>25,400 sq.ft. $200
NAME C�A_NCE: $10
AMOUNT DtTE = S I��G�-
^""•"PLEASB TURN OVER AND C4MPLETE OTHER SIDE OF FpRM'""""
,
ADMINISTRATIOIV r ` ,
UNDEIt CHAPTER 152, SBCT1tJN 25C, SUBSECT7tJRT 6,TI�TOWN OF YARMOU'I'H IS NOW REQtJi�tED
TO HOLD ISSUANCE QR RENEWAL OF ANY LICEIVSE QR PERMIT TC? OPERATE A BUSINESS IF A
PERSdN1 OR COMPrkNY DQES NdT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
tNSURANCE. THE ATTACHED STATE Wt3RKER'S COMPENSATIUN INSiTRA1VCE AFFTDAVTP
M[JST BE CQMPLETED A]�TD SIGNED, OR.
CERT. OF INSURANCE ATTACHED
�
WORKEIL'S CQMP. AFFiDAVIT SIGNED AND ATTACHED�
TpWN OF YARMOUTFi TAXES AND LIENS MUST BE PAIIa PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERR�ITS. PLBASE CHECK#�PFROPRIATELY IF PAID:
Y�S_�,_ NO
NOTICE: PERMiTS RUN ANNtJALLY FROM JANUARY I fi0 DECEMBER 31. Ti' IS YU[TR
RESPONSIBt[.I'fY TO RETLJRN THE COMPLE'FED A!'PLICATIQN{Sj ANB REQ[JIRED FEE(S) BY
DECEMBER 31, 1998,
SEASONAL ESTABLISFIMENTS ARE TO CdNTACT THE HEALTfi I}EPARTMENT FOR IlVSPECTIQN
7-]0 DAYS PR10R TO OPENING FOR THE SEASON.
ALL R.ENOVATIONS TO ANY FOOD ESTABLISH113ENT, MOTEL OR PO4L {i.e., FAINTiNG, NEW
EQ[JIP'MENT, ETC.), MUST BB REPORTED TQ AND APPROVED BY TIiE BOARD QF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDiTIONAi RFGLj�A I'�i" dNS
POdLS
PddL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SBASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE'WATER TESTED FOIt
PSBUDOMONUS,TOTAL COLIFORM AND STANL?ARD PLA.TE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLC7SING: EVEItY OU7'i?OC1R IN GROL7ND SWTMMING PQOL MUST BE DRAII�iEt7 OR COVEREIJ
W1TH1N SEVEN (7) DAYS OF CLOSING.
FCIOD SERVICE
�ATE(tING POLICY�
ANYONE WHQ CATERS WITFIIN TI-IE TOWN OF YARM4UTH MUST NOTIFY THE YARMOUTEI
HEALTH LIEPARTMENT BY FILING THE REQUIRED TEMPORARY F(?QD SERV2CE APPLICAI"IQN
FORM 72 HOURS PR10R TO THE CATERED EVENT. THESE FORMB CAN EtE OBTt�IED AT 'THE
HEALTH DEPAR'fMENT.
FRO .NP� I?Ey."_+Eli,�'C
FR.OZEN DESSERTS MUST BE TESTED QN A MONTi-II.Y BASIS BY A STA"TE CERTIFIED LAB. TEST
RESULTS MUST BE 3ENT TO THE HEALTH I3EPAR'fMEN'f. FAILURE TO DC} SC?WII,L RESI3LT IN
THE SUSPENSION OR REVOCATIOI3 OF YOUR FROZEN DESSERT PERMIT UNl'IL THE ABOVE TERMS
HAVE BEEN MET.
OLJ�IT�E�AFES:
OLITSIDE CAFES(i.e., OLTTDpOR SEATING WI'TEl WAITER/WAI'TRESS SERVICB),�(J,�'Z Ht1VE PRIOR
APPROVAL FROM TT-IE BdARD OF HEALTH.
OUTDOOR COOKING:
Ot.PI7}OOR COOKING,PREPARATION,OR DISPLAY QF ANY FOOD PRODUCT BY A RETAIL OR FQOD
SERVICE ESTABLISHMENT IS PRgIfIBiTED.
DATE:�.�� SIGNATt7RE: �G�r-,;�z.. U'K �C.l C,{�
PRINT NAME& TITLE: /'ln/1�- rn J C.e 7t " �IRFc��-{-rc� C'U.�t.0 QR�j °
J
°--•:,^ _�..�.:�,.__...�.. _ __ --��-....
_.
� _.__.
YARMUTJTH I DAY CARE CENTER EVACUATION LOG�iBemonthlv�
te T�e C mmen
�' ci�{ �'g � : `(�a e�cr ;h l��- u,e.�� , t -z vh ,•r,
.��;
-.M...
• ,
��,
_ ss� ,
�`=,,
,ti
,, ,r ,�..
a:�..� 3��,� i ���� �. .:4 r ..�c-x'., ; Y'i�„F+`, r a
q �.n�, ���A���
� rv . . W
�\
The Commonweallh ojMassachusetts
? � Department ojlndustrial.-iccidenLs
; 011/eea/Iares!l�at/iis
600 Washington S1ree1
Bosron, Mass. OZlll
W'orkers' Compensation Insurance Affidavit
Aooticant intormation: PlesseYRINTTe4.'idq
nam�1Z �Q � l�h la /K.UL�oa R1Rm/� V'teOBlO-nt �/JC� .
lucation RQ (Y.Qfn/1 ( S� /7'`/GMn/S /'/� �ZloO/
i
ctn ehene p �0�= ")')S—�p 2�Q
� I afn a homeowner pznorming all work myself.
� I am a sole proprietor _r.,+. ha�e no one ti�orkine in am capacin•
(�[ I am an employer pro�iding workers� compensa[ion for my employees working on[his job.
tomnam� nama S'�WIJ� -
address•
eih•: / eAene p: �
insur�nceco. UTJLa �jYvb/Io��S'LlYN/IGlr�j-'�(�Ou� oolicvt� ��� ���� _
� 1 am a solz proprietor. general contractor, or homeowner(circ(e onel and ha�e hired the contractors listed belo� ��ho ha�e
the follu�cing ��orkz;;' ,ompensation polices:
�ompanv name•
address•
� cirv: ohone p:
insur�ncc to nelie�•q
com a�ny name•
a�drcs••
titv• nhoee M•
insuranee co. eoRev M
•
Failurc to seeure coveraee�s requfred uoder Seenoo 25A ot MGL 152 u�lad to t6e iopo�iuoe W erisiW peaaltla of�O�e ep to 51�00.00 a�d/or
ooe years'imprisonment u w�ell a tivil peealNt�in Iht form of a STOP WORIC ORDER�ed a Ilet of 5100.00�d�r a�aiert ma 1 a�denta�d that a
- copy of thb�ntemeet may be forw�rded to the ORce of Invatig�tiom of the DU fw eovera{e veriflutloa.
1 do�hrreby cenijp der tbr paint a perta(ries ajperjury rhat tha injornmtion provided above is uru and conect
Signaturc � � �l �� Dste (t�T�-�
Printname Y�.- �' I • . Ll � PhoneM ��—��5 ��a Z� o
., oRri�t use onl�� do no�writt in this�rta to be eompleted by eity or town oflltial
� city or town: Y�M��TQ _ � permiNiteme M n8uilding Department
�Littesio6 Bo�rd
� Q ehetk if immcdiate response ie required �261 �Selectmenb Oflfee
� pHealtE Department
conuct person: p6oat M:_ �508) 398-2231 eat. nOther
SCHOOL AGE CHILD CARE
TAR CERTIFICATION STATEMENT
Name of Program:1�rAl1_1c+�!� l ',1� ��� ( �p� �L/i-f��i/
� C�/�e �aL✓ ` ����Q /�v�1c'�/n�2-f� L�� � * * * � * * * ,. * � .� *
� * Please circle which *
* status applies to *
* your program: *
. ,r � *
* Profit Non-Profit *
* � *
* * * * * * * + * * * *
I certify under the penalties of perjury that I, to my best knowledge and
belief, -have filed all state tax returns and paid all state taxes required
under law.
, � �� ,��,u�
*Signa ure of Individual of By: Corporate Office ��
Corporate Name (Mandatory) (Mandatory, if applicable
,23 "] 32 �( � �2 G/z � �sy
**Social Security # Tate
(Voluntary) or Federal
Identification #
* This license will not be issued unless this certification clause is
signed by the applicant.
** Your social security number will be £urnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations . Licensees who fail to correct their non-
filing or delinquency will be subject to license suspension or
revocation. This request is made under the authority of Massachusetts
General Law c. 62C s . 49A.
FOR OFFZCE USE ONLY: .
� OFFICE OF CHILD CARE SERVICES
Name of Individual or Corporation
( last name first)
Address
Social Security or FID Number
' License Number
Type of License
Date of License
SACC
S/90
, , - THE COMMONWEALTH OF MASSACHUSETTS
. ' , � Executive Office of Health and Human Services
Office of Child Care Services _. _
Office of Child Care Services
FORM: TAX CERTIFICATION STATEMENT
Number: F-OCCS-98-03
TAX CERTIFICATTON FORM
Ausuant to M.G.L. Chapter 62C, sec. 49A, I cectify under the penalties of perjury that I, to my best knowledge
and belief,have filed state tax rerurns and paid all stau taxes rcquired under law.
p7 � / �/� T � .� c'^� / Qr�/✓LOU� I�� rl� /(I �`¢re ��AY�' P^
Social Security Number or Federnl I.D. # Program Name
�i�e �a�+ �h• �� ��e�m��h�1 a e
Cor�rate Name: (if different) �
6 �a / ! 49
Date ' /
bY: tT/csN�—
"= Signature Corponte Officer
May I, 1997 102 CMR 7.03(1)(d); 3.03(Ixa)39; Paee I of I
Rev. 4/22/98 5.03(2)(a)16; 8.03(6)
JUN-25-99 01 :39 PM M.E.SNALL_SC.�COL 82u :T8 T974 P. �3
. �
� 4y
.
• V � . � Y
� �T a
� � s N f�J � . �
e
w: ' � - ,� `� �
; .
�: • R �
m � .. .. .. .. .. .. .. .. .. .
. �� :
1� �
� Q. �. il � . . 4 M M
N � �� Z• � � � �
� • � �• � a .s e
� � ; �: <;
' °i: �' .. . .::
�, � Q• � ' , g E„: o .... :: : .. ..
. • 4� �
� M ' �. �.
� � � � : � � .� � � �a � ` .�
a �
,� W � : ' ' S' � � � �;
�W c� p+ '' ' e o • .. .. .. .. .. o � � '' 3
�' ,Q`' y a g
� 'M'�.r U ' � a. m ° � , � � �
� � ►�i � : o a +�: o
�►•+ � a : K � m m
a � r�+ � : �: �� � , ...,.. � `' . .. � � �
�`^ � + ("� r, . :: :. .. .. .. a .: :: :. .. .. -,
.�.� N y � : �i � a o � �
a�i A� �-
� S'J � ' C�. •~ i o� Y C
H �
. � 0¢ �( �� R a O ^��'
` Gtl N p �y Y �
,'�'y� � 'd � . # P� G. K t g
� a�. � V � � Q: � 14 c~i d � � O '�
� � : ti a
+ ,�y � � � : 4. W . .. y''
� a^i. F�f p'i . .tl �� � . .. .. .... .. � ..�. �� � IC
• ;� +�t H � a �: � c; '�i M 4 �
p •,+ �r � ' - .
0 -�' � � . � v: � �' � y °`�' �
�
� ; .� �, �: -. -. .- .. .. ,� �
:
'" "�' * .^i
«, �: � � �' t' a
t : g � G+. u �
�1 �T ,r,� y, a• � �� t_, r. �+
' � `00. AG � V �t ° •(=� •� .Y
� M; �; � �.. i j� A"r
s � : a, .. .... .... d y � ,�i� :�
� .. ° '' ...�n
_ 'tt - . � *► � .. � V�i
rI i i. � . O {f •• �
/ s� � C � � ±i a � V K�
V.. :M1.c�F Nx. �
� 'A N Sd T. . �'2'r
JUN-13-99 03 :59 PM M. E. SttALL_SCHOOL 508 778 7977 P. 04
a ---
� . $'
Y � �
� M � .
�� . � q �.'
�
� � � �
j1,1: � O
: �; � . . .. .. .. ... .. . .. .
a : � .
� ' �
M' �
�: : a: f� u
�n' � Q�L y � �
: �
N . �
• �: ,tl �
� y O � ' � �: � ' . . . . ..
. . .: : �.: �
.. : ... . .. . ..
� � Fq M ; �� � N � � �
•[�I Oi : d . �
� .
�+ `� V � : : � 8. � � '+ � o
� � W Q : : m G= '� yy a, �
� j� 'a • 'a, e' , . .. .. .. . C .� ,�
. .. o u S �
. � � � � • • v Y � .
� � � � � � � w o � � o
� : �: ; � . .. � : �
� � � w � : � � : � . . ..
� � � p �, ; � . � � :... .. .. .. U .. .. :: .. .. g s
r� : a � � J o, �
sw o � E � : � : '� � �� u �i u � �
� �' g V � : �, w r! ` �� U � � �
.. � '� ; � � , �` ,a o �
. . o .:
�+ � � i ' o .. .. .. .... � ..
��.y+ '•1 A��+ : � 1�� n� .� .. . .. � w
T:i al y : u a: � p' • `� �
fl � ",+ �"� ' m '� a T � �
g � a � : Q �. d r �, � ; .a
� � , ,� Z, r� N .. .. .. �. J � �`� rC
� � � . N.. . � N
� � O .! � .. �. .. .... . .. .
tl . � �: �� . �' A Y � .�.
�: N !1 rv � O
� .� �; a � �
� �: , � � � �. s�,
. V y 1 I
. � . O � W V � fM
. . p M► � �� � ...... .. . . . tl � � fA Q� µ � �
+� '�' . .
u G � Kfj
� b1 tl o o �. a t^ e�+y + � �4
� � a � � � � y �
�,�� q u
c
�
. �
JUN-13-99 01 :56 PM M. ". S'�ALL_SCF '10�. 508 778 79T7 P. 02
a
� :i
� : � � �
� � y
wl y M ZI
• � � • �
• O
. p1: � S �' �
: ' : �, .. .. .. .. .. .. .. .. .. . �
m' o
.� . oo- �• � �' .,
h :
�. �: ro o u � '�
� � : &' �@: M v' � . . �
s i� • �: �: � . ..::
� � r, . : �: m .. .. .. .. .. ... .. ., .. �
tY •
� � .. , ,,. � ^: ,:.; . ,S
, r � .; � � a l4 �
S.� y: : a v
� � .' ;.., a: o �' �. .. .. .. .. a � � � �
„�. �� �• � � M b d1
� .i� C
� Z �� � � u o � 8
� � � �,,,� �j: � u � a � o
�-+ a �: � h � � � .
�- � � o �: .. .. .. .. .. � .. :: :. .. .. � N �
�, � ,� � � o � e
� o m W �. $ •� a " ,, � m �
� u� t� z
C tt � ., C .a
a C"� �� N. : tl m � � '�'� �' a
'�' y y 'tj
�` 0 4 w a� a `� . a� 5
� ; o: �
. Q ,�, � L7 , , m '� a 3 � ; v
y �,'. � � � �' � �: o � ti •S
� '•.
. .. .. .. .. . .. .. . .
� � � r"+ M; .� a' � . g �
a N a
� � E'' �: � � � � Q°� a
� �I: o: : c�
a W . � �; y 6 °' �� w
� � V : � z' :: :. .. , . .. . �. " � �
H. . .. .. g �
. �:
� � m: '�'m' a�, .; �n
ti . .� •: �� � � y .e �
�. • ' � �
� ' y ^' �: � �S 3 � a' .e
l.. � sr; �
,.. o � . �: � .. .... .. .. o m IS ,�_. .,,
..., � �.
v p� a y-• c :.. � � N i_V' "i 1� £
� � � � r a .. n ti 5~ ��
'�I.:/��� �4 1' .
�� � • • " � � , .. IV
�?
pF'Yq BOARD OF
o� �y T O W N O F Y A R M O U T H sELECT,��Ev
11�6 ROIJ"I'E YS SOUTH Yr1R�lOUTH MASSACHC,'S�1'CS(1266�--F492
� MATTACMCES � rO�I�
���.,,,,,,�.�*��d' Telephone (�OS) �9�3-2231, Ext. 271, 270 — Fax (5�8) 398-`>365 .��,{INISTRa-COR
Robert C. Lawtc�n,Jr.
MEMO
TO: Building Inspector
Boazd of Health ,�
FROM: Robert C. Lawton, Jr��i�
Town Administrator
SUBJECT: Fee Waiver
DATE: May 12, 1999
�
At their meeting on May 11, 1999, the Boazd of Selectmen voted to waive building pemut and •
health depaztment fees for ' ` " for the� o€
.. . , . ' �t
their property at 367 Route 28, West Yarmouth.
Please keep me informed as to the total which is forgiven as a result of this vote.
Jd
07
t,�
��
Prinle�un Fecyeb0 Paper � ,
� F°"" YIF'9 Request for Taxpayer Give form to the
(Rev. December t996) �dentification Number and Certification �e4uester. Do NOT
Department of Me Treasury
� send to the IRS.
imana aevenue Semce -
Name f a Iaint accou or you ch�p¢q yaur nam see SpxiXe Imtructions on page ,)
r �iJ C.�i� a/ � 1/ec.o R 0 �e��+,. e✓G
` Business nama,if tliHerent from ahove.(See gpeciq�Instructions on paga 2.)
`o
c .
y Check appropnatd box: � intlivitlual/Sole propnetor � Corporatlon � Partnership � Other ► f J/�]`�.- (��(. _�� �i I
. �y°� Aoatlress(number,straet,and apt.or wite no.) RequesteYs narne antl atlaress(optionaq
a D ,Q.(� � �7 �4 �z
City,state,antl ZIP cotle . � -
Taxpa er ldentification Number IN List account num0er(5)here(optional)
EMet your TIN in the appropnate box. For '
individuals, this is your social secunty number ����g���y�umbar - �
(SSN). However, if you are a resident alien OR a
sole proprietor, see the instructions on page 2. �
For other entities, it is your employer �q For Payees Exempt From Backup
identification number(EIN). if you do not have a Withholding (See the instructions
number, see How To Get a TIN on page 2. �Pioyer ide�mflcanon number on page 2.)
Note:!f the account is in more than one name; �
see the chart on page 2 for guidelines on whose Z 13+71�3 I Z IK I�I 3 I �I �
number[o ente�. �
Certification
Under penalties of perjury, I certify that �
t. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
2 I am not subject to 6ackup withholding because: (a) I am exempt from backup withholding;or(b) I have not been not�ed by the Intemal
Revenue Service(IRS)that I arn subject to backup withholding as a result of a tailure to report all interest or dividends, or(c)the IFS has
notified me that I arn no longer subject to backup withholding. .
Certification Instructions.—You must aoss out item 2 above if you have been notifietl by the IRS that you are currently subject to backup
withholding because you have failetl to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not apply. �
For mortgaqe interest paid, acquisition or abandonment of secured property, cancellation of de6t, coninbutions to an individual retlrement
anangement(IRA), and generally, payments other than interest and dividentls, you are not required to sign Me Certification, but you must
provida your cortect TIN. (See the instructions on page 2.) .
Sign `/'��� / c /(}G
Here Signature ► ���,�,,/l LJ(A�� Date ► �L /20 / l !
Purpose of Fortn.—A person who is include interest, dividends, broker and 5. You do not certify your TiN when .
required to file an information retum with barter exchange transactions, rents, required. See Me Part III instructions on
the IRS must get your correct taxpayer royalties, nonemployee pay, and certan page 2 for details. �
identification number(i'iN)to report, for payments from fishing boat operetors. Real CeRain payees and payments ara - �
� example, income paid to you, real estate estate transactions are not subject to exempt from backup withholding. See the
trensactions, mortgage irrte'rest you paid, backup withholding: py��� instructions and the separate
acquisitlon or abandonment of secured if you give the requester your correct InsVuctlons for the Requester of Fortn
property, cancellation of debt, or TIN, make the proper certifications, and � W-9.
conVibutions you made to an IRA. report all your tazable iMerest and � �� �
Use Form W-9 to give your conect T1N dividends on your tax retum, payments Penalties �
to the person requesting it(the requeste� you receive will not be subject to backup
. and, when applicable, to: withholding. Payments you receive will be Failure To Fumish TIN.—If you fail to
- sub ec[to backu withholtlin rf fumish your correct T1N to a requester, you
� 1.Certify the TIN you are giving is � P 9 ' are subject to a penalty of$50 for each
cortect (or you are waiting for a number to 1.You do not fumish your TIN to the such ftiiure unless your failure is due to
be issued); requester, or � reasonable cause and not to wiilful neglect.
2 Certify you are not subject to backup 2 The IRS tells the requester that you Civil Penatly for False Informatlon Wth �
withholding, or furnished an incortect TIN, or pespect to W1fiholNng.—If you make a
3.Claim exemption from backup 3.The IRS tells yau that you are subject false statemeM with no reasonable basis '
wrthholding if you are an exempt payee. to backup withholding because you tlid not that results in no backup wRhholding, you
Note:lf a requester gives you a form other �K�� Your irrterest and dividends on are subject to a$500 penalty.
than a W-9 to request your TIN,you musi Your tax retum (for reportable irrterest and Criminal Penatty tor Falsifying
� use the requester's form if it is substantially dividends only), or _ Intortnatlon.—Wllfulty falsifying
smilar to this Form W-9. . � _ � 4.You Go not certify to the requester certiFlcations or affirmations may subject
What Is Backup WithholdiogT�ersons that yau are not subjec[to backup you to cnminal penalUes inctuding fines .
making certain paymerrts to you must - wfthholding under 3 above(for repoRable � and/or imprisonmeM.
wfthhold and pay to the IAS 31% of such irrcerest and dividend accounts opened Misuse o(T1Ns.—If[he requester -
paymeMs under certain conditions.This is after 7983 only), or discfoses or uses TINs in violation of � �
called "backup withholding." Payments . � Federal law, the requester may be subject
that may be subject to backup withholding to civil and criminal penalties..
Cat.No. 1023t7( . Fortn W-9 fRav. t2-96) �