HomeMy WebLinkAboutApplication and WC - - �-��� od-
�. � � TOWN OF YARMOUTH Boardof
alth
� = ll 46 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSE 02������� H alth �
�i° Telephone(508)398 2231, ext. 1241 ni '�inn �'
Fax(508) �6Q 3472� �� ` �,�� � 5 �G�� ,�
,. .. :.• HEALTHDEPT.
SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT - 2013
NameofEstablishment: ��i�Q.11(��Q,1� TelephoneNo.: .,fIUY-�qM-i'I�I�-I�
Taac ID (FEIN or SSN): ,�
Address:^.`��J� l )�'L 0 1'(`�'1, �()ll—Y� ��(LI' (11,�� u�-t0�y
Mailing Address (If different from above):
Owner/Corporation Name:�C�. � L-Yt�'_ Telephone No.:
Owner/Corporation Address: ��� 11.��LA�O S P(�, �����Q]�t S.�ll�
Manager's Name: S(�__�y___�c)!�UC9� �Y1 Telephone No.:
Manager'sAddress: � � e1LL TSIQY�C� Y'{,. i �C11l�liUlf�'li A� nZ`�-Zo3
Under Chapter 152,Sea 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 renewai or issuance ofyour pernuts. Please
check appropriately if paid: yes ✓ no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device X �{ � � a-�-O•o�
#OF TANNING BEDS:� #OF OTHER TANNING DEVICES TOTAL�
TANI�TING DEVICE INFORMATION:
Manufacturer Model Number Serial Number Tvne of Bulb
o.� � �t'1 �UCUS �Q i �2-1�
Norice:
PERMITS RUN 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 of Health may be required prior to reop ng.
DATE:_��3 '�Z SIGNATURE�l��ZO.�(l�J j��l�
,on�nz
� The Commonwealth of Massachusetts
Department of Industrial Accidents
Offtce oflnvestigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aaalicant Information Please Print Leeiblv
Business/Organization Name: Z,S�QPV� �A,1'1
Address: � 3���'11��5 ���
City/State/Zip: �,� Phone#: ,�j Og-?���-�-j U�17
Are you an employer?Check the appropriate box: Business Type(required):
_ � 5. ❑ Retail
or art-time .* 6. - . _ _ _ _ _ _ -__,_
�,/ p ) ❑ RestauranUBaz/Eating Establishment
2.L✓1 I am a sole proprietor or partnership 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] g• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have �0.❑Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ We are a non-profit organization,staffed by volunteers, �Q���n S �
with no employees. [No workers' comp.insurance req.] 12.[�Other
'My applican[that checks box#I must also fill out the sec[ion below showing their workers'compensa[ion policy infoimation.
"IFthe coryorate officers have exempted themseWes,but[he corporation has o[her employees,a workers'compensation policy is required and such an
organi7ation should check box#1.
I am an emplayer that is providing workers'compensation insurance jor my emp/oyees. Below is thepo/icy information
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy t1 or Self-ins.Lic.# Expirarion Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure cover�e as regu'ued under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
— -- - -- -- -
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fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalfies in the form o�a S`TOt�UIt�6ifl5E�iia a nne-- -
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby ce Jy,under the ains and penalBes of perjury that the information provided above is true and conect.
S�i�n, ature362�a��(�*'� Date: I I- I � "I Z
Phone#: �Vb-3��-�`���7
Official use on[y. Do not write in this area,to be completed by city or town officiaL
City or Town: ��)� Permit/License#
suing Authority 'rcle one):
Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.
Contact Person: Phone#: �B c3�(��a� )G �Zy�
www.mass.gov/dia