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�,s °� `� TOWN OF YARMOUTH Boazdof
Health _.,.
= 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
�E� Telephone(508)398-2231, ext. 1241 Health
Fas(508) 7603472 FEB 0 9'PO`�4"
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SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT -2014 ������i
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Name of Establishment: 15�qnC� I AY1 Tax ID (FEIN or SSI�:
Address: �31� �1h1kPS i�Q-�'�'1 � S611�'1 aCtYYY1CSl.l�n� NV� 02_l.0l0`�
TeiepnoneNo.: `�v�� 3q�1-4�1y7 E-m�i: ��lnrxi-Fr,nrn�� rsmra;t,. nef.
Mailing Address (If different from above):
Owner/Corporation Name:����.�'1 C_. Telephone No.:
Owner/Corporation Address:
Manager's Name: �QYL�'1 �c��I c�t�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 permit 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 of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes ✓ no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device �2"Za`u �
#OF TANNING BEDS:_� #OF OTHER TANNING DEVICES TOTAL y
TANNING DEVICE INFORMATION:
Manufacturer Model Number Serial Number Tvae of Bulb
i�iov�l �un I-�.u�S 'Fla4sh�p 122cck�
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. Failure to do so will result in closure of your
establishment until the required application(s)and fee(s)aze received. A hearing before the Boazd ofHealth may
be required prior to reopemng.
DATE: 1 I I ln Il'!� SIGNATURE�� ,�� ,��f���
10/OB/13
`
, . .
. � The Commonwealth of Massachusetts
Department ojindustrial Accidents
Offzce oflnvestigalions
' 1 Congress Street, Suite Z00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�blv
Business/Organization Name: SS�AYII� 1 cl Vl
1
Address: __�� ��� 1�'PS G-�-h
City/State/Zip: s. yL�YYY1b1k-}h , N1f1 (2(,(,� Phone #:_�-3qy -y��17
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.� I am a sole proprietor or parMership 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 corporation and its officers have exercised 9. ❑ Enter[ainment
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,
with no employees. [No workers' comp. insurance req.] 12.� Other
*My applican[that checks box#I must also Sll out the section below showing[heir workers'wmpensation policy information.
**If the cotporete officexs have exempted[hemselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1. �
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensatiou policy declarafion page(showing t6e policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. ]52 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP VJ�RK ORBEP.and a ime
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 certify,under the pains andpenalties ojperjury that the information provided above is true and cotrecG
Sig�ature• l/�v�Q����cc�a� Date: Il- ln- � '�
Phona#: '�U2�- 3°I�I-�-{1��.17
O�cial use only. Do not write in this area,to be comp[eted by city or town officiaL
City or Town: Yi�¢t�n.ma Permit/License#
ain�AuT on �rde one):
oard of 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#: - /Zy�
www.mass.gov/dia