HomeMy WebLinkAboutApplication and WC � (S(ANp7/}ni
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°� TOWN OF YARMOU�� T, e � �
� ���:,
� � 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 07,(64-2 51 ��`?��2 �
o..o� Telephone(508)398-2231,ext. 1241 Q� ���
Fax(508)760-3472
JAN 16 2015
SUN TANNING ESTABLISHMENTS HEALTH DEPT.
APPLICATION FOR LICENSE/PERMIT-2015
Name of Establishment: ZS�OtYId TQYI Taz�ID (FEIN or SSN):
Address: o��J� l��h�-�o� �r�Fh, S��i-Fh �larmm�. , nn,q bu�i��l
TelephoneNo.: �ZS�- 34�1-�-1�IU7 E-mail;.��� i 1�� ffY1 nS�",. a� .
Mailing Address (If different from above):
Owner7�orporauon Name:�cc�C, � �71C . Telephone No.:
Owner/Corporation Address:
Manager's Name: ��� ��IUGc.I-P�'1 Telephone No.:
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 pernut 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 Insuraace�davit
must be completed and signed.
Town of Yannouth taYes and lieps must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes ✓ no
LICENSE/PERNIIT REOUIItED:
Fee: $55.00 per device x � = � 22o�oO �
#OF TANNING BEDS: #OF OTHER TANNING DEVICES TOTAL�
TANNING DEVICE INFORMATION:
--- -------------_ ---- ------- - ___—_ _ _ __. _ ._---- - ___ –
Manufacturer Model Number Serial Number Twe of Bulb
� ,5 �C_U5
Notice:
PERMITS RUN ANNiJALLY from January 1 to December 31. It is your responsibility to return the I
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 heating before the Board of Health
may be required prior to reopening.
DATE: I Z�2�5'��-{ SIGNATURE:��,(1�J rAd
�irosi�a
a� � � The Commonwealth ofMassachusetts I
Department ofindustrialAccidents i
Office oflnvestigations
' l Congress Street,Suite I00
Boston,MA 02I14-2017 i
www.mass.gov/dia ;
Workers' Compensation Insnrance Affidavit: General Businesses
Apnlicant Information Please Print Le¢iblv
t / I
Business/OrganizationName: � Iq,l'll� /Giyl i
Address: 231� (��'y�p �� ��
Ci /State/Zi I
tY P� J �G,YmcM,�, YV1A 6� (nlo� Phone#: �D� 3q<-I -�-1�-I�17
Are you an employer? Check the appropriate box: Business Type(required): �
1.❑ I am a employer with employees (full and/ 5. ❑Retail
t - * R
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. '
[No workers' comp. insurance required] 8• ❑ Non-profit ,
3.❑ We are a corpomtion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing '
no employees. [No workers' comp.insurance required]* 11.� Health Caze
4.❑ We aze a non-profit organization,staffed by volunteers, i
with no employees. [No workers' comp.insurance req.] 12•❑ Othe�'
•Any applicant that checks box#1 must aLso fill out the secdon below showing their workers'compensation policy information. I
"•If the colpmaze office�s have exempted themselves,but the coxporation has other employecs,a wodcers'compensation poGcy is iequi[ed�d such sn
organi�aflon should check box#1. � � � -
I am an employer that isproviding workers'compensaiion insurance for my employees. Below is thepolicy information.
Insurance Company Name:
Insurer's Address: I
City/State/Zip: I
Policy#or Self-ins.Lic. # Expiration Date: �
Attach a copy of the workers' compensation poGcy declaration page(showing the policy nnmber and ezpira8on date), i
Failure to secure co_ve;age_as required under$ection 25_A_of MGL c. 152 can l�ad to the impasition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalfles 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 cert�,under the padns and penalties of perjury that the information provided above is true and correct
S�nature: �lr�����j zL Date• I.Z-Z�— I LI
Phone#: SU8• 3�t�-1���-l�(
Official use only. Do not write in this area,to be comp[eted by cify or town offuiaL
City or Town: Permit/License#
Issning Authority(circle one):
1.Board of Health 2. Bnilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person• Phone#:
www.mass.gov/dia