HomeMy WebLinkAboutApplication and WC � . �-�a -o�a- �N� TA a
� � `� TOWN OF YARMOUTH Boazaof
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1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-2 51 ����ea���
'°+�" Telephone(508)398-2231,ext. 1241 p
Fax(508)760-3472 �CL U�����
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SUN TANNING ESTABLISFIbIENTS
APPLICATION FOR LICENSE/PERMIT -2012 �, � �-� _���k
Name of Establishment: ZS�Ca Y1 C�Tu Yl Telephone No.: J�•�q�I-u y�I7
Tax ID (FEIN or SSN):
aaa�ess: �3� l,vhitvs �G-l-h S. ya,�mo��.� , MA o.,trnc.�
Mailing Address (If different from above):
Owner/i.orporation Name: -C���Y1 L - �elephone AFo.r �y-��14�-
Owner/Corporation Address: �� ��h�.�S �QT Vl ��L� M/� U�loL�
Manager'sName: )(x1�Y1 j�/������i�iD� TelephoneNo.:
� . . (�_ � �
Manager'sAddress: �I I'I�I� �'S�(]Yl(I P�. .� J(Al"1(l1A)1C•�l �V�IA 1��3
Under Chapter 152,Sec.25C,subsection 6,the Town of Yannouth is now required to hold issuance
or renewal of any license or permit to operate a business if a person or wmpany does not have a
certificate of Worker's Compensation Insurance. The attached State Worker's Compensation
Insurance �davit must be completed and signed.
Town of Yarmouth taxes and liens mu�Y be paid prior to renewal or issuance of your pernrits. Please
check appropriately if paid: yes ✓ no
LICENSE/PERNIIT REOUIRED:
Fee: $55.00 per device = �2ZO•00
#OF TANNING BEDS: #OF OTHER TANNING DEVICES TOTAL �
TANNING DEVICE INFORMATION:
Manufacturer Model Number Serial Number Tvue of Bulb
/_ ,l; „ .. _� •
u ��c:�� rlcu����i'z o�
Noc��e:
PERMI'I'S 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 of Health may be required prior to reope ing.
i� `
DATE: l Z./I �l� SIGNATURE: //i?�JL��(��.lf-GL.
�onm,
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' � The C�mmonwea/th of Massachusetts
Department ojlndysdia/Accidentc
N�[aM�
600 Wos/+iegioe Strcey �FJoor
Bostow,Maa. Bll/I
Worken'Co-pewtlN irea�ce AiHd�v�
.la�t i�tlftatlMt Pl�ut rRIN1'luilit
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8 t�,eumeown�per�iog.n wat myselr.
I�a sok prop�ktor sod tisve o0 oea wohiryt in gay ap�city.,
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eea�re:
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