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BOARD OF F[ fiALTH , �
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ST,iN TANNTNG ESTABLYSffiVIEN1'S � ?t� ; �� t �'b�
APYLICATION FOR LICENS_ ERM1T-,� �Yt ��,
Name of EstabGshment: �/✓�r �`�1 � � � Tdephone No.: ���' �3o c
adaress: i l t_o�,� �oK� Q r P vc
Mailing A.ddress(If diff�►t from above):
Owner/Corporarion Name: L✓ � y 2'h L . Telephone No.� ��� '2 3°�
Owner/Coiporation Address:
Manager's Name:C- I�' �� /�a h i L , Tdephone No.: �76D �a 3 d.1
Manager's Address:
Under Chapter 152,Sec,25C,subseetion 6,the Tovm of Yarmouth is uow required to hold issuazice
or rencwal of any 6cense or pemrit to operate a business if a person or compa�does not have a
certificate of Worker's Compeasation Insurance. 17�e attathed Stace Worlcer a Compeneation
Insunnce Atfidavit must be.compkted and aigaed.
Town of Yarmouth taxes and li�s must e paid prior to renewal or issuance of your permits. Plwsc
check appropriatelp it paid:yes no
LICENSFJPERMIT REOUIItEn:
Fee: 550.00 per device
li QF TANHI1�iG BEDS� #OF OTHER TANNYNG DEVICES I TOTAL I
TANNYNG D�VICE IIVFORMATION:
Nlaanfattunr ModellYumber $erial 1Humber Tvoe of Bulb
S��I��l'LL 'f ✓' sd —ycv►�r� S� �AQ��y� GG.I/�a �VX
NOhCt:
PEIZMITS R11N ANNIJALLY from Jam�ary I io December 31. It is your responsibLity to return
the compl�ed application(s) andreq w�red ite(s) bY December 31. Faiiucc to do so will result in
ctosure of your establishment until the required application(s) and fee(s) are received. A hearing
before the Board of Hcalttt may be roquired prior to r�pening.
DATE'-- I 2 ) 3 ►I 0 � SJGNATURE:� rri,�.�
11/04
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