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°' � TOWN OF YARMOUTH ��f
� Health
1146 ROUTE 28,SOUTH YARMOUTH,MASSACHiISETTS 026 y����O�
Telephone(508)398-2231,�xt.24t> r � N��
Fa�c(508)760 3�72 �, ;�
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SUN TANNING ESTABLISHMENTS
APPLIGAI'1[ON FOR LICENSE/PERMIT-2010
Name of Establishmeat: ��°lll c� �� vl�tJ Teleohone No.:�8� 7��—Z�O 0
Tax ID (FEIN or SSN):
Address: I 1 �vn� �a n�( ��('✓�
Mailing Address (If different from above):
Owaer/CorporaYion Name: W�* y `�n c. Telephone No.:
Owner/Corporarion Address:
Manager's Name: C ��}�- /�t u�i y Telephone No.:��-7�0— 2?ou
Manager's Address: �,
Under Chap ter 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 compan� does not l�ve a
certificate of Worker's Compensahon Inswance. The attached State Worker s Compensation
Insurance Affidavit must be compieted and signed.
Town of Yarmouth taxes and liens must paid prior to renewal or issuance of yow peimits. Please
c6eck appropriately if paid: yes no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device
#OF TANNING BEDS: 2 #OF OTHER TANNING DEVICES TOTAL � t I 0.Oa
TANNING DEVICE INFORMATION:
Manafacturer Model Number Serial Number Tvce of Butb
TJ�ir��Snc{ rya� S�ada2z Cr S� 71r� �1/
�Qqr���+Yt, 14VINiH4 Svh�02Z f1' S I'�Y � r� UV
Notice:
PERMITS RiJN ANNUALLY from January 1 to December 31. It is your responsibih'ty to return
the completed applicarion(s) and required fee(s) by December 31. Failure to do so will result in
closure of your establishment until the required appUcation(s) and fee(s) are received. A hearing
before the Board of Health may be required pnor to reopenmg.
DATE: NG"✓ ��{ �u� SIGNATURE: ���(P�;f�_
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� The Conemodwealth ofMassachusetts
Department of Indusdial Accidents
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600 Washington Streey f"'Floor
Boston,Masc. 011ll
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❑ I am a homeowcer perfocming all wock myseiL Project Type: ❑New Cmstr�on❑Remodel
❑��I azu a sole�pmprtietor and have no one wodcing iu anY�ca{racity• ❑Building Addition
�}'I am an employa prcrviding workers'compeasati�for my employees wodciog on this job.
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