HomeMy WebLinkAboutApplication and WC . , . . � /o-o01
°' `� TO WN OF YARMOUTH
� s�a or
Health
1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 02 �O��
� Telepho�(508)398��1,ex,t:�241. � � � - ni���
F�csos>�6b-aa�z + �`q.: Nov ? � 7���9
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SUN TANNING ESTABLISHMENTS
APPLICATION FOR LICENSE/PERMIT -2010
Name of Establishment: �-S�U,n�. I G�. Telephone No.:Jr(�-v�qy•U4�(
Tax ID (FEIN or SSN):
Address: � 3D WYLI�QS �Q� St)l.l-x� �ll�;�'11� M�4 il Lla(n�
Mailing Address (If different from above):
Owner/Corporationl�iame: ���� ��'1C • TelephoneNo.:
Owner/Corporarion Address:�3� �U�'U;�QS ��, �Y.)IJI�V. yCLYY11(Sk;w1 1'�/lfa
Manager's Name: �(�� f'1 Uu(?li,�,p� Telephone No.:
Manager'sAddress: �I �Ie�t�,�.S�QY1C�, �• �AYItIbUiC,�ly '�/� bL5�3
Under Chapter 152, Sec.25C,subsecrion 6,the Town ofYarmouth is now required to hold issuance
or renewal of any license or pemut 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 Yazmouth tases 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
#OF TANNING BEDS:_� M OF OTHER TAIVNING DEVICES TOTAL �2�•o0
TANNING DEVICE INFORMATION:
Manufacfarer Model Number Serial Number Tvoe of Bulb
'F , �f���2zo7
Notice:
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 wn'll result in
closure of your establishment until the required appl�cation{s) and fee(s) aze received. A hearing
before the Board of Health may be required prior to reop g.
DATE: � I ,l � IO� $IGNATURE:� ���,/'�_
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wo!oc
r � The Commonwealth ojMassachusetts
Department of[ndustria!Accidents
NieINl�n
600 Washington Sdeet, �°F[oor
Bostan,Masc 01111
Worke's'Compeesatioa fasaraece Af[idavil:Boildio�JPlembing/Ekctrical Coatractors �
A�olitaot fefama8n: Pk�e PR_�T le$61�
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a�ss: Z�� w f W�K-� �� �
��ty S, `)�rmrn,r� �re� r�nA �o���l o�# �-��i4��-►y7
a,otk s��e location rrwt ada.essr. �
❑ I�a homeowmer perfotming all work myselt Project Type: ❑New Constcuction QRqnodel .
[�I arn a sole�proprietor and have no one wocking in any�capdcity. ❑Building Addition
❑ I am an anployer providing workeas'compeasation for my anployees wodciog a�this job.. . .
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