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� � °' `� TOWN OF YARMOUTH Bo�daf �
Health
= 1146 ROUTE 28,SOiTTH YARMOITI'H,MASSACHCTSETT,S 03864-24451 -
�• Telephone(508)398-2231,ea�.�123� ;. n
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Fa2c(508)760-3472 v; � � �
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SUN TANNING ESTABLISHMENTS HFALTH DEF�T.
APPLICATION FOR LICENSE/PERMIT-2011
Name of Establishment:_ �S 1(�(� �L1,1`l Telephone No.:�l� 3 q� y LI UT
Tax ID (FEIN or SSN): ��
Address: d3� Il�.�� PGI�-I�l� r) , yQ,l� mi�u,d'�. N� �Ln n�1
Mailing Address (If different from above):
Owner/Corporation Name: � 1 1 �, ,T�'1C. Telephone No.:
� j � _ ___ ____
Owner/Corporation Address: .-J.3� I��p R�(.�'Vl , S `'�U,YYY�iSlk�'�� 1,'W�l CS1Id �{
Manager's Name: �(;�y'Zt�'� IC(}(�pf��1D�1 Telephone No.:
Manager's Address:, '/(I C I LL �S 1LiXld a"t� S(;1Y�C�4lIL C� . N� ����
Under Chapter 152,Sec. 25C, subsecrion 6,the Town of Yarmouth is now required to hold issuance
or renewal of any license or pernut 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 ta�ces and liens must be paid prior to renewal or issuance of your pemuts. Please
check appropriately if paid: yes �/ no
LICENSE/PERMIT REOUIItED:
Fee: $55.00 per device
#OF TANNING BEDS: #OF OTHER TANNING DEVICES TOTAL�= � 7_7_U 00
TANNING DEVICE INFORMATION:
Manufacturer Model Number Serial Number �pe of Bulb
�.¢�,1Ct.� _ __ __ __ ----_ _
� ws �t��L2..c:o
Noti�e:
PERMITS RLTN ANNUALLY from January 1 to December 3 L 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) are received. A hearing
before the Board of Health may be required prior to reope g.
DATE: I � � I O I(O SIGNATURE: ',� /p��p,�
�azono
, , . �
. ' The Commonwealth of Massachusetts
DepaKment ofledustricl Accidents
N/IciN�
600 Washingwn Sireet, 7'"Floor
Boston,Mass. 02I11
Workers'Compeesatioa Iroeneee ARidavk:goildiog/Plambie�/Ekctrical Coetraetors
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work site location lfiill address);
❑ I am a lameowcer per('olmmg all work myself. Pro ect T
[��I am a wle proprietor and have no one workin �n an ca oi � �' ❑N�'Conshucdon QRemodel
B Y pa ty. ❑Bwlding Addition
❑ I arn an employer providing workers'compensation for my employees working on this job. ���.
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❑ I arn a sote proprietor.8nersl eo�traeror,or homeowner(cirdt one)and have hired the cootcactas listed below who�have
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