HomeMy WebLinkAboutApplication and WC , " �'!/— o o a- �.a�r�,-�-��s
� � TOWN OF YARMOUTH Boardof
� xealth
1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 0266 -24451 Health
� Telephone(508)398-2231,e7ct. 1241 �
F�(508)760-3472 � �"' �=i1� �
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SUN TANHING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT-2011 y��TH Dk`R7.
Name of Establishment: P��1�e �- �t �l� t I J Telephone No.: ��'"�����3Q"
Tax ID (FEIN or SSN): �� � �
Address:-��� Pon�� I���'✓C
Mailing Address (If different from above):
Owner/Crnporatian�Fame: `'V � � � �h� • - Telephone No.:
Owner/Corporarion Address:
Manager's Name: C`� ��- �I�o n,•Z Telephone No.:
Manager's Address:
Under Chapter 152, Sec. 25C,subsecrion 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 Compensarion Insurance. The attached State Worker's Compensation
Insurance Aftidavit must be completed and signed.
Town of Yazmouth ta�ces and liens mus e paid prior to renewal or issuance of your pemuts. Please
check appropriately if paid: yes no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device
#OF TANNING BEDS:_� #OF OTHER TANNING DEVICES TOTAL oZ � �� I O .O�
TANNING DEVICE INFORMATION:
Manufacturer Model Number " - SerialNumber Twe of Bulb
pf5r��4Gc� �5hhiti3 S�S�qZz�tl' SA !� 7TSS �_
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Nohce:
PERMITS RiJN 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 establishwent until the required application(s) and fee(s) aze received. A hearing
before the Board of Health may be required prior to reopenmg.
DATE: ^f U✓ y- , �� 0 SIGNATURE: /��cr
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The Corainonwealth ofMassachuseds
Department oflndustria!Accidents
N�feaN�
600 Washingwn Sbeet, 7`"Floor
Boston,Masc 0211 J
Workera'CompensaHoe Imaranee AffldaviN gaildiop,/PlembiepJEkctrical Conhactors
name: �AllT1 1 .L 1 �- �� ��4b1C � f i��'ICJI �rlr/'IQr1��
address: �_� O�'1� �
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work site lacatioo lfiill address):
❑ i am a homeowner perf'ortmng all work myself. Pro ect T
1 YPe: ❑NewConsWction ❑Remodel
❑ I am a sole proprietor and have no one wofking in any capecity, ❑Building Addition
[j�I am an employer providing workecs'compensation tor my employees wo�king on Wiy job. �
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