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Home My WebLink AboutApplications, WC, Licenses Prior to 2010 i . �e9�o6�' w�N� K�� ; �► °� `� TOWN OF YARMOUTH Bo�dof Health , 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHLJSETTS 02664 2Q1� C5� � O �e�DD Telephone(508)398-2231,ext. 241 Faac(508)760-3472 �=�- 0 4�H��'" '�;'� � F�,�I"Pf.DEPT. Si7N TANNING ESTABLISHMENTS_ � `" ' ,,n,,� �� APPLICATION FOR LICENSE/PERMIT-2009 (�' � �ll�" Name of Establishment:�Q t1 c�" �i � h cJ 1 Telephone No.: �8� 760 -230 0 Ta�c [D (FEIN or SSN): .��}' �} � (, Address: �1 �Ut� � {�C�h� {irit vL Mailing Address (If different from above): ' Owner/tosporaTion IVame: w-G } _ _ �hf . -- �elephone No : Owner/Corporation Address: �� L�h °I p�� i; ✓� .S- 4 C r/l v�a-{ Manager's Name: C �� J�-�o�r r 2 Telephone No.: Manager's Address: 3�'S (�6I �u1 poll ��l S�.cl j vr� �j .� Q(��L 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 compan� dces 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 6ens mus�be paid prior to renewa(or issuance ofyour permits. Please c6eck appropriately if paid: yes ✓ no LICENSE/PERMIT REOUIRED: Fee: $55.00 per device = �//o.00 #OF TANYING BEDS: Z #OF OTHER TANNING DEVICES TOTAL Z TANNING DEVICE INFORMATION: - - - - --- - - _ _ __ Manufacturer Model Number Serial Number Twe of Bulb � [c�r.�''Stic� 15tin� .Sv�C��i2'l,�rr� ��7*Y v� �Gr� `lLc ��L� :.. SvlG�c72I!✓ cS�Sb �_ —�—w+,�q J NOYICC: PERMITS RLTN ANNUALLY from January 1 to December 31. It is your responsibility to retum the completed application(s) and required fee(s) by December 31. Fa�lure to do so will result in closure of your establishment until the required application(s) and fee(s) are received. A hearing before the Boazd of Health may be required prior to reopenmg. Da�TE: IUaV � 3 `)-t1A`.,� SIGNATURE: tT , + � The Co�nmonwea[tk of Massachusdis Dcpartwieat oflrtdr�strralAccidents �arNrw�s 6p0 Washington Street, �''Floor Boston,Mass. 011ll We�ern'Com�eneatioe ieseaoce Affidavit:Baildiog/Plumbieg/Ekctrical Coatrxton �: a aaaa�s: v c o . 'v Gr u :��6 �— 7 O— Z.�dC . wodc site locffiim fvll add[ss: � Q I am a wrer perfo�mu�g all w�lc myself. Project Type: ❑New Construction❑Remadel ❑ I�a sole pri�or and have�oce woilciog in any capecity. ❑Building Addition � �' I am an emp�oyer providiog w�kas'compensation fce my empbyees wodcing on this job. . S� ----- --'�_-` ---:._ _ _ .. u��c 1 � . . . _. . . .. .. .. . . . . . . .. .. ad�as: citv- d�me Y: � ��`�t� v a L — S - 3 7873S— Ul� ,. , :, , _�.k.��Y_..., .:, ❑ I am a sok ,yna�al eestracter,or Yomcaw�er(drele owc)and have hirod We cowtacwcs listod betow wlp have the followiog 'c�mpensation polices: r �d�en: . - - -�ih: - - - ` - - - _ . .. BMieY: _ .. � - _ ____. _ _ __ - _ . .___ . M _ _'^�r, , .. . _ . . . . � . . .. . . . . . .. �. . . , . . , _. _ id�rlaa: d�s: I v�aee p- __— _ ____ __# _ - ___ ;� .; ., ,�.;� ;;: Fa6a�cr�cve n�eqWdudvSrd��25AdMGL1S2mkadblYei�pMdtl�adaf�YalpafNbdt�e�b113KMudNr �)n�' sweindNperMlnisfYeferoKa31'OtWORKORDERud�BvedSiM.6ladryaplat�e. lndnaOWfdta s�qdpflt �rylefrw�NYtlnO■oeN��1YeMARRrenaa�ev'nleniN. � ��henay cnsy .wr.r fMeve4v mdven�Nies ofP�ynry aY�Me infw..otan prewuad eboce fs b.e m.d oormc � SiBorta¢ � /Z�G�/ar— /r Date � I J� �1(/!Y . .��i e�� o �Z� Pno«a %78— �� 1-8`�8T Y�IBfGNh'� dBMt�1�kCI�tW�lfJ46LO�bYd(YKWIil�Pjil � dl]H fMIB: M �@�/§�� ❑��BtOm� ❑AeeYi[��6Rqa$ed ❑Sd�n' pmCe . s �� P��, ��t ! i i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiJMBER: #09-002 FEE: SI10.00 This is�o Cenifv�he� WGY Ine. d/b!a Planet Fimess 17 Long Pond Drive. South Yarmouth. MA IS HEREBY GRANTED A LICENSE For COMMF.R('IAT. TANNiNC; FA('ii.iTIFS (105 ('MR 123.000� TWn (2) TANNTN(; DEVi('AS This penni[is granted in confom�ih�a-ith Article V I of the Sanitan�Code of The Commomvealth of Massechusetts,and expires December 31 .2008 unless sooner suspended or recokzd. DecemUer ll. 2008 BOARD OF HEALTH: S J�4'XC�PI.P�X 'U ('.YIQ.NlfJ 'J�� tCiiL � ce G. Murphy,M , CHO Director of Health � � � o�—oo l oF�Y`�R �� `�o TOWN OF YARMOUTH . C� C� GOMC� D 0 y 114G ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 0266 . 51 �"�,',;;�;`6�� Telephone (508) 398-2231, Ext. 241 — Faac (508) 760-3472 �EC 1 4 Z�� sonxv oF xEnLTx . -' HEALTHDEPT. SUN TANNING ESTABLISHNIENTS APPLICATION FOR LICENSE/PERMIT -2008 Name of Establishment:��Q V)e'� t-< �V1 e.rS Telephone No.:Shc3— 7S 0— 2-Tv o Tas ID (FEIN or SSI�: ��'�— � Address: �� i �c� �T i V C' S - � ti i c�} n�� Mailing Address(If different from above): Owner/Corporation Name: �� h L Telephone No.: q ?8 — � �J—��'� Owner/Coiporation Address: Manager's Name: C��' � ,� /y o: �� Telephone No.: �G� — �3c7 U Manager's Address: Under Chapter 152,Sec.25C,subsection 6,the Town ofYarmouth is now required to hold issvance 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 Affidavit must be completed and signed. Town of Yannouth taxes and liens mus be paid prior to renewal or issuance of your pernuts. Please check appropriately if paid: yes no LICENSE/PERMIT AEOUIRED: Fee: $50.00 per device #OF TANIVING BEDS:� #OF OTHER TANNING DEVICES U TOTAL � TANNING DEVICE INFORMATTON: ManufacYarer Model Number Serial Number Tvae of Bulb C�hdyZzlrr � vl� tl6 Wo7�3 �,�� Sv5 �52L� Cr � �/�-}� 1� w��ys4 �/I/ Notice: 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. FaiIure to do so will result in closure of your establishment untii the required applicarion(s) and fee(s) are received. A hearing before the Board of Health may be required prior to reopening. DATE: L��-�� SIGNAT[JRE:_ r� ivo� � Printed on � � Recycled Paper �'CIp �Liberty 6SUING OFFICE 181 MU�Llal� Wodcers Compe�on and INFORMATION PAGE Employers Liability Policy �.-1CCOUN'C NO. SUB ACCT NO. Libe�iy Mumal L�surance Group/Boston 1-347875 000p LIBERTY 1NTUAL FIRE INSliRANCE CO. 16586 ' POLICY NO. TD/CD SALES OFFICE CODE SALES CODE N/R IST WC2-31S-347875-017 XX X WFSTON 102 REPRESENTATIVE 3000 2 YEAR ASSIGNED 2003 Item 1.Name of WGY IlVC Insured DBA WORLD GYM OF YARMOUTH FEIN 54-2072916 Address 11 LONG POND DR RTSK ID 000341101 SOUTH YARMOUTH,MA 02664 Status 03- CORPORATION Other workplaces not shown above: SEE TTEM 4 Mo.DayYear Mo.DayYear . Item 2. °ol'zcy Period: F:o� 94-03-29lF1 to 09-93-28@3 12:01 AM standard ame at tl�e address of[6e insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liabiliry Insurance: Part Two of the policy applies to work in each s[ate listed in item 3A. The limits of our liability under Part Two aze: Bodily Injury by Accident 100,000 each accideat Bodily Injary by Disease 500,000 policy limit Bodily Injury by Disease 100,000 each employee C. Other States Insurance: Part Tluee of the policy applies to the states,if any,listed 6ere: SEE END WC 20 03 06A D. This policy includes ihese endorsemencs and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4.Premium- T6e premium for this policy will be determined by our Manuals of Rules Classificatlons Rates and Rating Plans. All information re u'ued below is sub'ect to verificaaon and chan e b audit. Prem�um Basts Rates LINE 110 Per 5100 Es[imated Code Estimated ot RE- Aauual C1aSSificaUoOS Yo. To[al Anuual Premiums muaeretion Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 192 ( MA ) Total Estimated Annaal Premium $ 1,614 Interim adjustment of premium shall be made: ANNUAL Tlils policy,including aIl endorsements issued therewith,is hereby countersigned by Aol6orimd Re mati. Dale 09-17-07 Loc.Code Term. Oper. � Audit Basis �Periodic Payment Rating Basis Pol.H.G. ' Home State Dividead RENEWAL OF: 09-17-07 NR MA WC2-31S347875-016 cPo aoso R� Copyright 1987 National Council on Comper�setion Ireurance wc o0 00 ot n Insuretl Copy THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-001 FEE: $100.00 This is to Cer�ify tl�ac WGY Inc. d/b/a Planet Fitness 17 Long Pond Drive. South I'armouth_ MA IS HEREBY GRANT�,D A LICENSE For ('OMMER('iAT. TANNING FACiLiTiES j105 CMR 123_000) TWn (� TANNTN('�DEViC'F.S_ This��ern�is�r�nte��a�$�pmu�with Article VI o�t�e Sanit��ode of The Commonwealth of Massachusetts,and exp s ec er esssoonersuspen orrevo December 20.2007 BOARD OF IIEALTH: S � t "J�,�,q�{�,t�ce aixmarc 3 ' ..lY. , / ruce G.M hy,�IP ,R.S.,CHO D'uector of Health . . �07—�a� �c�e4 �`�°o '� o�''�`�R � `�� YA � � Q -� � � " [ " � � r� z , �,; - _� � 1146 ROliTE 28 S�L'Tf1 YARMOUTH MASSAGHUSETTS 0266� 451 � HATTACXEES � � DEC 0 4 2006 � �'+Eo.,pp1Lo,b��Cd' Telephone (50�f) 398-223I, Ext 241 —, Fax (50$y'7�-3472 s o a �z � o F x � 'n z, � x HEALTH DEP-f. SUN TANNING ESTABLISHMENTS APPLICATION FOR LICENSE/PERMIT- 2007 Name of Establishment: L✓G � `G�,C . d Sy 1'�r,��- Fi-iS�nTelephone No.S�8-760-�-�"'c T�ID (FEIN or SSI�: Address: �� Pa� �/i 2 Mailing Address(If different from above): S4�S� Jwr.er,'CurYorsYian Narne: W`a �I Z � C Teleptc;,��:vTe.: Sa8--24 o�•22e o OwnerlCorporationAddress: �� LuyeS P�� 1�/�'�C S` �4r.� a�.�� f�'i� Manager's Name: C�`i�-� /�•�P Z 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 permit to operate a business if a person or company does not have a certificate of Worker's Compensation Insurance. The at[ached State Worker's Compensation Insurance Aftidavit must be completed and signed. Town of Yarmouth taaces and liens must e paid prior to renewal or issuance of your permits. Please check appropriately if p�id: yes no LICENSE/PERMIT REOUII2ED• Fee: $50.00 per device #OF TANNING BEDS: -- #OF OTHER TANNING DEVICES_� TOTAL � TANNING DEVICE INFORMATION: - - - __ - - - - Manufacturer Mode9 Number Serial Number Tvae of Bulb Svti �Szz< �f.- S � - 9G --vI� R SDDQoi�sr V µ 5��, Q� z� � l.,� SO- y6-vU� $��3� U. �4o �i� Notice: PERMITS RiJN ANNUALLY from 7anuary 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 m closure of your establishment untd the required application(s) and fee(s) are received. A hearing before the Board ofHealth may be required prior to reopenuig. DATE: i 1 � 3� U 6 SIGNATURE:�� r� � IO/06 � Pdnted on ( Recycled ��y Paper �''\ The Commonweakh ofMassachusetts Departnrent of Industrial Accidentc N�ic�Mrl�lfNrs 600 R'ashington Street, 7t8 Floor Boston,Masc. 02111 Wor�ers'Comp�satioe lasea�ce AiSdavk;B�ildiog/plumbug/Ekctrical Coetraetors ��tl�: � i'La�e tRil�il'�. - name: address: ciN stah• zio� oh�# work sire location(full add�essl: ❑ I mm a homeowner perfo:ming all work myself. Project Type: ❑New Constcucti�QRemodel ❑ I mn a sole proFsietor and have no oce wodcing in aey capacity. ❑B�rilding Addition � I am an employer providing wo�fcas'compensation for my employees wodcing on this job. �m�..,�: w G `� T5 � - _ _ _ __ __ .��: t � ��r,� -��d _C.�;,� _ �t�.: S- V s.ha� k� f'1 /�- 0266 4 �r: ��. Li�t��7 l��'rv�l �s �. �,: wca-3�s- 3y �a�s_o� ` , :.�,��._. ❑ I am a sole pr�ri�or,geaeral eo�tractor,or lemeawwer(circle awe)and Lave hiied H�e confsac[ois lis[ad below who have We following wcekers'coinpensa4on polices: �v m�e- ad�as• t3tY' �lt: 4�aiee w. �p aenouv�me• �• �" o�re M� �d. � oeliev A ��.° �, . . � . . .. . .. � ..�.T�. F�ive Y aavc a�era�e n�eq�ed uJQ Sedle�2SA KMGL 132 eu kW b IYe I�pNIW�fvW W psdtle da de t*b f13M,M Wl�r�� . . .__ . eoE�n'�liesaeaf a�wd u dvY owltlo le�t�r�_dl 32'Or WORI�.ORDE ud�ese d_S1M.N f�y gdOt�e. 1 odeewri.pM_a.__.__._ _ npyatWeahtsmtay6efarw�rddblYeOmccdlaweN�tlwdHeDlAfiravengeve�nWe. . - i�tiaeey��.af �,.der tMe palna anJpenehtea ojperjrry rAer Me iwfone�tioa provileCelnae G 6re ail cerrecc s�s� /� mn r��i�u 6 Priet name VS C 1 •2 2 o Phoce# 9�d'��{ ��S�� om�w ax.wy ao eaf...tfe r this a.n u ae�siple�br dlr ar w...meid � .. dyorfewa: P�K �E�� ❑eYMc H1mme3�le�sme b�ai'M ��[Bsard QSdc�n'a O�m �tlnMY Dep�t na4R pens°' Pb�e 8; � l�a s,�mo�l THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERIVIIT NLTMBER: #07-002 FEE: $100.00 Th�s is to Cemfy thac WGY Inc. d/b/a Planet Fitness 1?Lons Pond Drive South Yarmouth MA IS HEREBY GRANTED A LICENSE For ('.OMMRR('iAT. TANNfNC,FA('Tf iTTF4 4105 Cll� 12'i 000) TWn(Z�TANNTN(}1�FVT('FC eT� S t is n�[e�l}n�rnitv with prticle VI o�t e S�it�y�ode of The Commonwealth of Massachusetts,and unIess sooner sus�en or revo January 30_2007 BOARD OF HEALTH: � : �• �� '� �i� ' R.N. Bruce G. Mu�p y, S.,CHO Director of Health r �� . oF ,�.�R ,�06 —QO � �,� �� TOWN OF YARMOU � � 0 � '� r°' o � y 2 2 2005 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 0 664-445 � MF4TTACMEE�S 'r Telephone (508) 398-2231,Ext 241 — Fax (508) 760-3 2HEALTH D PT. � 09GOP�lta�b � 'tl U B OARD O F HEALTH �685� l!`^ � SIIN TANNING ESTABLISHMENTS , ,1 � j 'i �� APPLICAT'ION FOR LICENSE/PERMIT- 2006 � , y ; „� _ ' Name of Establishment: P��h e � F�� h e S S Telephone No.: S�- �60- Z7o v T�m �nv or ssrp: _� Address:�1 Loh� Pond dr;,.e S- `��rna ��} � Mailing Address(If different from above): -s�t/ti� - --- Owner/CorporationName: 1i✓ �i � T� C. TelephoneNo.: -�08�76o-27oc, Owner/Corporation Address: � �l I��h C C a�^� ��"� S- y �/i1 a ��'{ Manager's Name: G 1 i �� M v H,'2 Telephone No.: S��'-�6�-Z36� Manager's Address:_ �U�rhe, � Under Chapter 152, Sec. 25C, subsecrion 6,the Town of Yaz-mouth is now required to hold issuance or renewal of any license or pemut 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 ofYarmouth t�es and liens mus be paid prior to renewal or issuance ofyour permits. Please check appropriately if paid: yes no LICENSE/PERMiT REOUIItED: �r $�fi.�(i��avi�e , �� .��(.�S #OF TANIVING BEDS:� #OF OTHER TANNING DEVICES� TOTAL�_ . 'I'ANNINC DEVICF, INFQRMATION: Manufacturer Model Number Serial Number Tvae of Bulb _Svh �sz�<� rr S�46-V �� Spo6oy-a4o ii1V i� Notice: PERMITS RLTN ANNUALLY from 7anuary 1 to December 31. It is your responsibility to retum the completed application(s) and requved fee(s) by December 31. Failure to do so will result in closure of your establishment until the required appGcation(s) and fee(s) aze received. A hearing before the Boazd of Health may be required prior to reopemng. DATE: ( � OS SIGNATURE:�I�� ioros � Printed on Recycled � Paper _ � , ' `�� The Corrmonwealtb o Massochusetts .�_----� r = Dcpartment of lndashial Accidentc - = N�'INrw�e 600 R'askingmn Strcet, �F/oor - Bostay Mess. 021I1 L5�' �/Q Worlcezs'C�pasatio�I�eeaece A�davk: v�v lectr�ed Cwtrxtors .._ . 1� 4. .� r..�ot� . ... br.,yi5 �`� L.:Sh"A� � . m .... . � .. Rsr Z..� {�v'� . L9mC: 'd�IC98: S1H 318[C' fJD' OAO�E M WOI�CS11C�OCffilm�f0ll 8�fG33�: ❑ I am a 6omaowner pe�forming all wak myself. Project Type: ❑New Cmstructiao DRemodd I�a sok�...y idoraod have no one w ' in any Bwl ' Addition t.. . : .,:- . �:;. � -•. K.��:�j:.� .- .. . I am an lo er providing wakas'compeaaazim fa my�pbyees wodcing a�n t6is job. . ... . . . �.,�: �/1/�� Th C - - -- - - �: � ��h� Po�� D�� _ _ �__. So:.�-� y �.na��l /�/� ��: �08- �!o—�3�c < <i .. k�=• � 2 z — oU ❑ I am a sole propiie[or,ge�enl co�traetor,or Yomeo�vw(drde owe)and have himd the contiac[as lis[od below w1p have the following wo[keis'compen4ation polices: a�: dU' nl�e li: # _ »Y'r�a w, xr ,. x , � �5 � fi , .a.2. ,�s'az +_ : �._ +F _w�.. .._. ._. . _ . .,.. . ._ . S$IWR1�e: �llN: C�' oi�!#• � ' " � ' :.:.... . . ... . .� .. r;b p �., e . , � � 'S'`� " �,:'. F�veYxene � �.� . a � ,SY'.w;t§� d�:�:�i"?�` .x.,* 4 fia"t'�`* � ., . , , ; .,. � awer�e 'e9drM��dv See1Mi 2SA sf MCL Iffi nu Ind b 1Ye hRwiWe Ka4�ia1 pe�Mn da de R b SI SN.M dhr ••�r�+'�•r•..�.�..�n.iw�ru�rK..n sror wowc oaneR m.�.tsi�ao�.a.y.��.�...asa.w.w�.e,- npy�ttlb Ma6eoe�dy 6e ferwaMM M tle O�c dLveNl�m d He DIA tar teverate�Ite�. /lo her�eby ceraFJy rnler Me pelns and pendtles ojperjrry tMat Me infonsaRon prodJel ebo�u arxe and co�rrct Sis�anre�—� /� tbre l,� G' d S Primname �1V3;�� 1� . F�I`Z�-�0 P6one# r�a' — �6o—Z7ao e�eNl ex enly do not w�Me Y[hb area N Ae onpkled Dy dtY or bwn a�ial eily or fown: �q �Be�� ❑cYeck if imardiat rcapeme ie reqaired ❑�e�� 'a O�ce ❑11nM!Dep�dee[ � ��N P�� pho�e#; �Q InvicdSrytlON) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-005 FEE: $50.00 This is to Ce,tify that WGY Inc. d!b!a Planet Fitness 17 Long Pond Drive South Yarmouth MA IS HEREBY GRANTED A LICENSE For COMMHRCTAT,TANNTN('�FA('Tf.TTTFS (10 CMR 1 000) nNF. (1) TANNTN('rnRVi('.R This��is�r�nte�l�n�fgru��with Article VI o�t�e Sanit�ry�Code of The Commonweatth of Massachusetts,and e� er ess sooner snspen or revo Febmary 2.2006 BOARD OF HEALTH: B ' ' _ ��e .� lta��, �flrus(fae�a��,Q./�. ce G. Murphy, ,RS.,CHO Director of Heal