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Home My WebLink AboutApplications, WC, and Licenses Prior to 2010 . �oR-�a� �, °' `� TOWN OF YARMOUTH �� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHIJSETTS 02664�2445��. :, � _ � �• Telephone(508)398-223 i,ext. 241 � j;� (`��s , � I �� FaY(508)960-3472 ��, � � NOV � 6 �uu� SUN TANNING ESTABLISHMENTS HEALTH DEPl . APPLICATION FOR LICENSElPERMIT- 2009 Name of Establishment: �5 l QY1C�. � �n Telephone No.:S�' 3q�-I-�-1�4�-17 T� i� �FEnv or ssrr�: � Address: ��JD W��5 �a�� S. `lCl(YYI6LC� � �-l0�o'T Mailing Address(If dift'erent from above): _ _ _ O�vuerL�nrpoLati�n TI�,,,P:---- 1Ct t�C,.-�hC.. Telephone No.: Owner/Corporation Address: o?3]� 11.1�1.1�_S �� S 7CiA'IY�6v..-� IUI.,� Manager's Name: �y�'� �t'��VL Telephone No.: Manager's Address: �] I�'I�'I Lt, '�S�G Y1C� � `�Ild W1C�1 NW DZ-5�23 Under Chapter 152, Sec. 25C,subsection 6,the Town ofYazmouth is now required to hold issuance or renewal of any Gcense or permit to operate a business if a person or compan� does not have a certificate of Worker's Compensation Inswance. The attached State Worker s Compensation Insurance A�davit must be completed and signed. Town of Yarmouth ta�ces and liens must e paid prior to renewal or issuance ofyour pernuts. Please check appropriately if paid: yes no LICENSE/PERMIT REOUIRED: Fee: $55.00 per device = �Z7�•O� #OF TANNING BEDS: � #OF OTHER TAN�IING DEVICES TOTAL� TANNING DEVICE INFORMATION: Manufacturer Modef Number Serial 1'umber Twe of Bulb �2ov G 1 Svv� rac.�s � 2Zcm Notice: PERMITS RIIN 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 apphcation(s) and fee(s) are received. A hearing before the Board of Health may be required prior to reope�mg. DATE: I � '13�I}� SIGNATURE:��Q,(y�.�j� >� � 1101'OB : . �\ The Comraonwealth of Massachusetis Department of Induslrial Accidents M�N�GNs 600 Washington Street, 7`"Flaor Boston,Mass 02111 Workers'Compeesado�Insesna Affidavih Buiid9ag/plambiaglEkctricai Contraetors Ane�t�wfsaHal• Ple�Pl��1T kv961v �: Z�,l and lci.�n a�5: a 3>> I�h Q s �.��. SiN J� `�1��rn DZ/�'7"V\ state 1 v Y�7 zip VHP�0 7 obone p ✓�Cl-��'t U �1�-l�1� � work site lacation(full addresst � . . Q J.am a homeowner perfocming ail waic myself. . . Project Type: ❑New Construcaon QRemodel [v]�I�n a sole�proprietor aod have no bne wocking in�y capacity. ❑Building Addition ❑ I am an employer provid'wg workers'compcasation for my�ployces wodcing o�n this job. . compav�r. � . . . . . . . � --. __. _. _ . _ ___- ._---- - -- _ _ ctir: � . . � . nyo�e p. . . . In ea p -..� _, . ,. , : � ,�,-,�a, ..K 4->;: ❑ I am a sole proprie[oy gwasl eoetraetor,or Lomeowwer(circle oneJ and have hired the contrac[o�s listed below who have iLe following waake�'compensation polices: eomoa�v�ane• �� addrna• ai.: ��. ieeea.m ca . . � P�y�{ . � . � . . . � .. . _ . . . . ,.. . . _ . .. . . ,�',r.r �n;.: �z�tme• addren- � � . . � � � � . oYe�e M- � � . . ��5°i. � ..P°�� •Y�� . .:,_ �- , ,. ,.. ... :. a , :,a� : ; ., a m.�.T�?. x.��; Fa9ns i�xeve wvaage n�eqeOM odv Satlw 2SA HMGL 152 eu Ind b He 4�p�iw Kvi�ial poaltln�a�e�bfiJM-M aNa'� eee.ynn'I�Wsammt n we�n dvY ptaaltln la t6e[orq Na STOt WORK ORDEA ud�Bse dS169.0!a Aay atalmt we. 1 odqahatl Imt a . . ..�.q�r�ra.�.ew��!-�.�fieawrdaQSsrieO�es� sfffieDGtmr � . .. � . l�*e�iptl� swn+E��c+Me�tlet___— ____ - ._ ___ . ._ _ . _. /da hereby`�f�rnder�t�he,p�ains�nJpesrlyra ojperJury H�at Mie lwfora�mton provided ebarie fs arre/wAcarrecR � s;so.��,��i�li/'-'mL9�l�� u I I� I 3/r� Print name � ��()C�dd,� r�. Phone#��.'3Q U �L�L-/�7� . emew me enry ao■a.rrke m tms,.e�w eemmplefM pr.dtr er w.n.�dai . � dtywtawu: ..P��{ ❑BoldioBttPu�o� ❑eheck ffimsW&'eapeme b reqdred . . � ❑SdMmee OfBee . oehdpema: ��, �� P+�dat lmwca�.mml THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLIMBER: #09-001 FEE: S220.00 Tl�is is to Czrtifv that (��iack inc dM/a Tsland Tan 23II White's Path, �outh Yarmouth, MA IS HEREBY GRANTED A LICENSE For COMMERCIAL TANNING FACILITIES (105 CMR 123.000) FOUR(4) TANNING DEVICES. Ihis,gennit�s�ra�ed j�c$t�fg��urv with Article VI of�h�Sanitar�Code of The Cotnmom�'ealth of Massachusetts,and exp� es c-em er uhless sooner suspen e or reco ed. December I 1.2008 BOARD OF HEALTH: .`�.¢e¢ft SPtq�� ✓Z..lv.� �Au�ilIIUUL �lQX.�CO .`�, .`K¢�l�Q�Y. �lC¢ �lll�ltfitllft ✓2o6ext s. `.�l3auuura, C�ex/# Qnre �'xeee6aum, J`Z..Ar. �. Bruce G. Murphy, MP , .S., CHO Director of Heatth T �� -o�- O� �yq� �$ '�� TCI �TI`�T OF YARMOU � � � od � o o "'j l 146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026 4443�i(, 1 J 2�� N MqTTACHCES � �'k,+,oqp�ta,b�� Telephone (508) 398-2231,Ext. 241 — Fax (508) 760-347 HEALTH DEPT. B O A R D O F H E A L T H -. 1�� SUN TANNING ESTABLISHMENTS � �� APPLICATION FOR LICENSE/PERMIT-2008 Name of Establishment: �.��C11'�LL TGc 1'1 Telephone No.: .�iU$- �v`1�-�4�-4�47 Tax ID (FEIN or SSN): �� _ Address: a 3]� l,��l LtQ'S ��--h s�� ya� m�u+t� , MA c�Z co�y Mailing Address (If different from above):_ Owner/Corporation Name: �U�Q.Lk- ,1.Y1 L. Telephone No.: OwnerlCorporation Address:%��LIJ�"LI�05l J�C+�4-�1_, S, y(i(Yyt Ul,(.-� , yV�� Manager's Name: �"� �i p�CX�..I�� Telephone No.: Manager'sAddress: '1 t��1�lC�,- �1[i,1� �� t• 5`i-r1c�l.t1�C,� YVI�'t LRS(o3 Under Chapter 152, Sec.25C,subsection 6,the Town of Yarmouth is now required to hold issvance or renewal of any license or pernut to operate a business if a person or company does not have a certificate of Worker's Compensarion Insurance. The attached State Worker's Compensa6on Insurauce A�davit must be completed and signed. Town of Yarmouth taxes and liens must be paid prior to renewai or issuance of your pernuts. Please check appropriately if paid: yesJ�no LICElYSE/PERMIT REOUIRED: Fee: $50.00 per device #OF TANNING BEIDS: Z #OF OTHER TANNING DEVICES Z TOTAL �-�- TP��lTNIllTG B�EVI(:� P.VFS?RA�.4'!'ION: Manufacfurer Model Number Serial Number Twe of Bnlb fIUV(A_� .Si�'✓I � �0[.,V S r��f�.C�� Notice: PERMITS RiJN ANNIJALLY from January 1 to December 31. It is your responsibility to return the completed applicarion(s) and required fee(s) by December 31. Failure to do so will result in closure of your establishment untii the required applicarion(s) and fee(s) are received. A hearing before the Board of Health may be required prior to reopenuig. DATE: �c� 'I� �� SIGNATURE�yy�"�`Y` ,J �iPo ttio� � Printe�oo ( Recyded � y Pape� • T � The Commonwea[th of Massachusetts Dcpartnre�t ofladuslrial Accidentc �ipd� 600 R'ashington Street, f"Floor Boston,Masx 021I1 � workers'compeesation Imaraace A�davil:Boiidiog/Plembiag/Ekc[rical Ce■hactors AuaNeaat Lhrofltet• P'Yue PRi[�TI'kp9blv �: �Sla�l� Ta.n aadress: ,Y3 Il �)}'L��PCrJ C ' . ci� �. \'(i1�1 �I�UVI� � Sf3te: 1�/1/l Zlo• UC.�1N�-__Dt1(tlIC#J�'��'�T�1Y� . WOI�C SIlC�OCBhm(�eddIC33� ❑ I am a hom�wcer perfotming all w�k mysclf. Proje.ct Type: ❑New Constcucti��Ranodel [�I am a sole gopridor and have no one wodcing in any capacity. ❑B�rilding Addition ❑ I am an empbyer providing workeis'compensati�for my employees wo�cing�tLis job. eompmv mr — - - - - addreas' �' oL�c M- iaoQSKe a. pelieL A . . . ;. . ,,... .. .,..:. . . ,>. • _�ss.;,se. >.e. c; ❑ I am a sole proprietor,ge�eral codtractor,or bmeow■er(drele owt)aed Lave ltired the co�actws Lsted below who have tLe followmg workas'compemsation polices: �v�- ad�eeas•, � d�' Marelh i_�a�oeea . . . . � co�v u�e- �n' d49: �� Inmareea. �y�t � . �itr�rWsY9 - . .. __ FaYeeixeoe n - - - ..,. . .� _ _ _-.-� .. , ._. , . . -,�.=. � ::�. a�aase �e9dRd odv SutlM 2SA dMGL 1!Z m 6ead b IYe Ir�fitlN d�l pnaltln dt de R bSIs3M,M YNM ene ynn'leprbemm�t a wf8 a dN pnaMb h tYe f��ta 3TOi WOAiC ORD6R nd�eae af S1M.N a dry apMt 0e. I udenh�d IMt a t�py NIYi Wiraeet ary be�te Ne Omte a[I�af 16e DIA trt�venge verNnlW. !Ao Aer�eby ander n1e pafna ewd penahfea ofperjnry M�Ms infweedton provlde6eberc u arve aet corv+eet ��i�e,l�, .�,/i�/,zl � . i a� r 81 c� P�� ara.h �ir�v ipn r�Ma 508= 39U . uL1�-17 e�Ll eu o.ry ao na.r�te h wb,.e.te ne m�ptled bM Wr or wvn em�vl � eilyerfswa: permitl6cedeM � ❑BnidioSDepaMmeet OLiccndm6 Bsard ❑ehed H�me�ale�eapeme h reqehed ❑Sdcc�m3 O�ce rnNSQ pvaoa. phwe 8� ❑HeMA D�nt c�smi mo» �Q THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF FIEALTH PERMIT NUMBER: #08-002 FEE: $200.00 Ilus is to Certify that ('niack inr d/h/a icland Tan 23D Wlrite's PaYh South Yarmouth MA IS HEREBY GRANTED A LICENSE For_COMMERCI i TANNIN FAC'ILITIES (105 C'MR 12� �001 FOUR (41 TANNING DEVICES. ILiP�ermit��ranted j3nlcy��fp�vdtv_with qtticle VI of�he�Sanitary�Code of ILe Commonwealth ofMassachusetts,and ex es ember uu ufiless sooner suspen e or revok Januarv 17.2008 BOARD OF HEALTH: ,�¢e¢K S�ll�� ,%Z,.I�I.� �t "�l�Zafy ��VlP4d .`�. .`KR.��PI� �[C¢ �.�!/lI►tl1/L 2atient s.�xoiurc, Cde�rP� Qnn C�'aceen�aum, J2.✓V. Bmce .Muiphy,MP , .,CHO Director of Health `�'`� �v�—�N o�' 'Y�� y `�' � � � � F YARMC� �J `I' I-� -- � T�[ r 5 � � I'� '� � 0 � ''3 i146 ROUTT 28 SOUTH YARMOUTH MASSACHUSF,TTS 026644 51 {/� ` UEC 1 8 2006 ` MATTACHEFS � �,„�oso�' o��,� Telephone (508) 398-2231, Ext 241 — Fax (508) 760-3472 I II O A R D O F H E A L T H . �..� �� -��'� �€P��a1 SUN TANNING ESTABLISHMENTS 2007 ��v APPLICATION FOR LICENSE/PERMTT Name of Establishment: _��4 f 1 f� TQ Ir) Telephone No. `�-�y y 7 Ta7c ID (FEIN or SSi�: Address:J,-�3 � �i )�'1 l�Q^� �GL�'1 � u Q.((Yl�I.l�'�l_. M A �2 Zo CL`� Mailing Address (If different from above): Owner/Cotporation Name: e-O�(LC.IC-- �-Y1 G • TelephoneNo.: �� I��h.i.tQs �c�lt_. 5 U r m ' Owner/Corporation Address:� —�-- Manager's Name: Q^r'^ �^ ��Y�r]!L� 1�� Telephone No.: Manager's Address: 7 n el� LSIn rld t��, SQYI'� "`� � � �� "� �--- Under Chapter 152,Sec.25C, subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any I�cense or Permit to operate a business if a person or company does not haue a certificate of Worker's Compensation Insurance. The attached State Worker's Compensation ;zas�ramce Affdavi4 mast 4►¢cocnpleted a:ed signed. Town of Yarmouth taues and liens mus be paid prior to renewal or issuance of your pemrits. Please check appropriately if paid: yes no LICENSE/PERNIIT REOiTIRED: Fee: $50.00 per device #OF TANIVING BEDS: Z #OF OTHER TANNING DEVICES Z TOTAL � TANNING DEVICE INFORMA'I'ION: Manufacturer Mode_, 1�r Seria�b�5 Tvae of Bulb ��— ' 12 LCX7 Ro�--- '�n _— — _— _— --- Notice: t�' PERMITS RITN ANNUAI-L I from January 1 to D Dec.�ember 3I1.1SFailureeto dosso wiut e��n eq hcation(s) and fee(s) are received. A hearing closure of your estabi shme t until the�r qw�S)app before the Boazd of Health may be reyuired prior to reop n+ng_ .,.rm� � ; ��/�/.�.i — D�1�':�� - •S'IC7NL�lvi�+J1 ��3Fauerdon � gecyded 10106 r �\ The Comnionweakh ofMassachusetts DepaRinent of Induslria[Accidenls �� 600 Washington Street, 7"'Floor Boston,Musc. 02111 1 Workers'Comp�satioe les�a�ce ASdavih Byildiog/p�ombieg/Ek�etrical Coatractors �ePRi11T1'tml`le � �: 15�in� .�nn %5nrnn i�tYlr�rLlph a�s: a3i� lti�h rt�S a-1-h �� S yarmou-}� �,,..�tA �o�o ��co� ��SnR �Q�1-yUy7 werk site tacaeon rrnuu��essr ❑ I am a homeowcer performing all woik myself. Project Type: �New Cams4ucdan❑Remodel [J�I am a sole pro�aietor and have no one wocking in any capacity- ❑Bwlding Addition � ❑ I am an employer providing wo�lcers'compeasation f�my�ployces workiog on this job. � . . compav rme- add'eas' dty oYoee B- i�ca. odkq M '_.. . .. . .. . . . .. : ,. .-.�,.., ,. .,., ❑ I am a sole Proprietoy 8eaeral co�tractor,or bomeowwer(cirele owt)and have hiied the co�actas listed below who have the following woikeas'compensation polices: ��v aame• . �s• �' nhe.s#• 3�sA�tt t0. � �rlh'P# _. ._... g�v�fwe• ��'!si' ChY� N�S�' �Y�f�O!eo. �y.o* ��i��M�f�/i�1rO1'Jx. . . . . .. ... . FaBve b xsme wvera�e n rtq�4ad oder SeWr 24A dMGL JSI m kW q IYe h�i1W dai�Yal peYtln Ka Le R b f1lM.M��d/�r,. �x Ynn'dPrrwwmt n�u eMp�tln h t�flarn ata 3T[K WORK ORDLR uRa me 1i3I00.0�i dry agtl�t ee. I arde�M IYt a eapy Nttl�starwmt m�y 6e t�nnMd 6e tle Omee atlev�lsn d He DIA fu twerage ver�ntln. I do Anrby ce[��pfy rndrr!th1e pabu anl penahka o.J'Perfr7 tlYet Me iwforw�tan provlded abnre ia lrre mrd cerrcct S,�nn�7�(eTlcr.v�L� Dste f � I ��V�O P�� nxnh ryl��r,i..l.�h P��# 5nR- �Fiy - UUy7 amad ofe.wy ao■w.Mfe a lm.,ra w ee mmpkfM pr�*r.r wvu.�cid .. cily er tewn: y P� �E Depar�eat ❑eheck i[Immedah Rapeme 6 rcq�ad �k��t Baard ❑3detdm't O�tt lnofaKpenaa: PheaeN, ��t THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #07-004 FEE: $200.00 ThisistoCertifythat l nia� inc d/h/a Tcland Tan 23D White's Path, South Yannouth, MA LS HEREBY GRANTED A LICENSE For CONIMERCIAL TANNINGFACILITIES (105 CMR 123 0001 FOUR(41 TANNING DEVICES �s.��ermi 't�s��cq�'tv_with��les��t .he o�tazv�e of The Commonweakh of Massachusetts,and ufil ded k Febmary 27.2007 BOARD OF HEALTH: B $. �O9doit, /y�., e�saNixWc e�/e��4lralr, Rrv., v�el�.� R�t 4. B� Gl� A��M�� R.N. mc:e G.Murphy, S.,CHO Director of Health • A,�� VC 'sV�+✓ � I ��F ��R�o �I' O W N O P YA R M `O U �''�'� lti .. _; '� `�� 0 9 ,2005 �; 0 `� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 0 6644451 � MPTT"`"6`4s � Telephone (508) 895-2231, Ext 241 — Faac (508) 760-3 2HEALTH 't�'r�� "�e,00..,�o� � B O A R D O F H E A L T H !1 �`�\ 6Y/ SiJN TANNING ESTABLISHMENTS � �a,o° APPLICATION FOR LICENSE/PERMIT- 2006 Name of Establishment: ��Q 1�L� �CI 1'1 Telephone No.: � -t-I�y�' T�ID (�nv or ssrp: ? Address: o��J7 ��11�D� �Q��,uf�JJLL11'�t1lA�l. � �.�D�¢� Mailing Address(If different from above): _ _ ___.____ Owner/CorporationName:�(�,C.�C.,1��')C. TelephoneNo.: OwnedCorporationAddress: �3� �'1,i�� t�� S,u( YV1I�lAt�� Manager's Name: �a � � d(Y,L��L. Telephone No.: Manager's Address:� �19��., 1.S�Y1[4 �. SC1,1'1�W�G�., � Under Chapter 152, Sec. 25C, subsection 6,the Town ofYarmouth 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 ta�ces and liens must be paid prior to renewal or issuance ofyour pemuts. Please check appropriately if paid: yes��no LICENSE/PERMIT REOUIItED: Fce: $50.00 p�deaice � #OF TANNING BEDS: Z #OF OTHER TANIVING DEVICES Z TOTAL � 'S'ANRTZ�?C �T��,'Z�f,'E IRTF�F�4�IAT:QP;T: Manufacturer Model Number Serial Number 'I`vae of Bulb i2C1Ur.� �t,�.+�. � ws '�1�;p�z�:�, Notice• PERMITS RUN ANNUALLY from 7anuary 1 to December 31. It is your responsibility to retum the completed application(s) and required fee(s) by December 31. Failure to do so wdl result in closure of your establishment unril the required apphcation(s) and fee(s) are received. A hearing before the Board of Health may be required prior to reop g. DATE: �a � a �U`� SIGNATURE: �l�f��r,(.��l.C�,�L� 10/OS � � Printed on ( Recycled ��3 Paper �� ' a r =� The Commonwealtk of Massachuse!!s �� -� �a ' Deparbirent of[nd�rs[ria/Accideirtc ' - — N�t'tM� � _- 60o wash;ngw,.snrey f"F�oo. , Boston,Mns�. 02111 . �"wo.lcas'comp�e.rfo■LaQa.ec n�Mvu:s.aaug/rl�m6ug/Elxtrkal cu,aaetors ,. m:.._. _ _�:— . .. .... .. .,�s'.'a,�"-�,S"'�'va , r ?�n'��;�:�. '.Pi�,' - ';� �: _ `��Q Yl f'l�¢,{�� S CIYd: �l f�G�U0..�� addresa: o( � � 1.��_�.�� . � ��,�t� �� MA riffc5�.c�� 9�� o��9y-u��7 ��S�n��m«�5�: 2�� lu�.x Pc�ln, S .�rnc�h. r�n,4 ��y ❑ I am a 6omaowm�performing all w�c myaelf. Project fType: �New Cmsavctim❑Remodel I am a solep[p 'dor aod have no ame wo ' in�y cayscriy Bwl ' Addition : . I�G� :��.%�'. �`.�^: �*'?�..��w.::. . ....... .. .�: . . .... . . . Q I am an�ployer provid'mg wakas'compeaceaan fa my�ployces working on t2iis job. a000��pat: - � � . �ar• dtv: _ - _ � . eYreN' . . R 0:.I am a sole prapridor,ge�eral e�trxtor,or�omeow�(drde owe)�d have haal the co�actois listed below wla have the following wake�s'comPeasaGon Polices: �v u�e: d�m: dtv nYae IF. M ,.oF..,�h.u+%��i+ti'hJa ..� . e.N3' r.^Fi . ` fi � v . � _� ,x�:�Y � ".--. � .. .. . ... . . . . .. .. . . .. �� N�� s�si lI: �� R ' .}ti ` ' a+ .. � ....a �..£ p _ a .' : r.. �: ..�tu i.-➢-�ly ..K '�f'�.n�'+}.�.�.Uti . .. . xYytl- .� `�� .XL�� - . FaBvelssaoeer�enrtq�4eAarlQSatiWBAa[MC.L131euledbtYel�p.rlMdat�YdpeW6nd�ie�pbSlJKMaM��r _ � ex ye�n`Imprioiient af we�u elvi peullfee in Ue fsrm ata STOr WORIC URDEH��eae K2160.M a day qaint ve. I�dvsshW tW• eepy rttih WhmM dy be tonraMed b the O�e atleve�pWes af Ne D1A tar esvenge verleeatlae. /40 6enby ce rnder Me/aint andBeneldes ojperJrry th�tlre uforls�ton provlded aboae ir arve aed romct Sig�mrc � �/ i�l Jli ll/!� I�te 1� � a l 0 S Printname��.l�� ) .Lfl I �V1 Phone# J�I�— �Cly �� a�efal eae ony aa nw w.ke r tols a.a m ee mmprled ey dry or M.m a�eLl city ar tewu• P��k ��m6�� . Qlleeo�fm�BeaN ❑ehedc NlmmeAh!re�peme 6 reqaired ❑Sda�ea'x O�ce ❑HeMb Il�ltbent mp�e[peraoa: pYem p; ❑Of6v lmucd SµZn0J1 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiIMBER: #06-003 FEE: $200.00 This is to Ceiiify that C n�ack Tnc d/h/a Tsland Tan 23D White's Path, South Yazmouth, MA IS HEREBY GRANTED A LICENSE For COMA�RCIAL TANNING FACII,ITIES (105 CMR 123.000) FOUR Ll TANNING DEVICES. Tlus�erntit�aoUed i�c��fg�i'lv_with Article VI of�h�Sanita�Code of The Commonwealth of Maasachusetls,and exp er uCuess saoner siupen or revo ed. January 27.2006 sonRn oF�ni.�: B :�$. it4.$., �a,r•a«� �'s�, �� e� R�t�. a�„� e�.� A�Ma�� j'�*�. .N. Biuce G. M y, H,RS.,CHO Director of Health ) o� Yq� ��d� �L r; rc iz, 'i ,,� ' rc; �� ,'�o TOWN OF YARMOUTH NOV292004 0 'H ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 HEALTH DEPT. �"�;�`;�`�s� Telephone (508) 398-2231, Ex[ 241 — Fax(508) 395-2365 ""� B OARD OF HEALTH , , A� � �..� ,� � �... �.:: C SUN TANNING ESTABLISHMENTS APPLICATION FOR LICENSE/PERMIT-2005 �-�/�`F� Name of Establishment: 15�GI.YI C� � QYl Telephone No.: 'Jq`�- ��`l7 ��d� Address: ia7 3 17 �h 1-��S 1�0.��l S, y ct,v m�u--� M A 01.lp�r�{ Mailing Address (If different from above): Owner/Corporation Name: C0�� I Y1C . Telephone No.: - - - ___ . Owner/Corporation Address: Manager'sName: �(Z)'� 1'�j�7CJ(�0.� ph TelephoneNo.: �O$-1}a$-�/;T�j Manager's Address: 7 '�'IPIC.�. `Thl(t(�d � . �. .�.�.Alld�Ul�lt , �„lA. (SLSZ�� Under Chapter 152, Sec.25C, subsecrion 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or pernrit 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 Af1'idavit 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/PERMTI'REOUIltED: Fee: 359��t5r devic� #OF TANNING BEDS:� #OF OTHER TANIVING DEVICES TOTAL 7 TANNING DEVICE IlVFORMATION: Manufacturer Model Number Serial Number Tvae of Bulb -�ov,a,l S�m �oc�5 ��ITp 12�b Notice: PERMITS RiJN ANNUALLY from January 1 to December 31. It is your responsibility to return the completed application(s) and reqwred 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 reop ntng. nA�: 11 �da�o4 siGrrA��z��E%a�� 11/04 � �� Printed on � Recycled Paper `�= Tke Cwninonwealth of Massachuset�c �� =-_ _= _ Deparlwiertt ofindwstrial AccidenLe ` _ �CI N� -= 60lI R'oshingtoa Strce� 7tb F/oor = „ � Bostor,Mass. 02111 � Workas'Compe�satio�Iis�a�ee Affid�vid B�dldi�/PhmW�g/EkMncal Co�traetmrs ,:..... , . . 4.x;:k?��*A .. ',.�,.rx uba;,.. . . ..., A -�: �x?' e,.:�z.ry;o-�"i�^'�*' `�' "" ..>. �Xt4.1K�- .4— OBmC: � aad�ess: �� .)�"l,��0 4 �l �;� 5 Ur,��xm�,�--I�, �� ao� W, at�4 �� og-�u uuu7 ��m«�,: ❑ I am a lameowna perfo�ing a1l waic myaelf. Projed Type: ❑New Cm�tiao❑Remadel mm a sole 'dor and have�oce in� B�ul ' Addition .. _ . .. � � . ,... � . . .. ❑ I am��pbyer providiug workecs'compeasatian f�my employces wodcing�this job. �n roc• . . . . .. .. . . . ..---- ---- -� - - �-- - . _._. _ . �4�. cbr . d�seM: ❑ I am a sole proprietor,ge�al eo�traetor,or bmcewxr(cirde awe)�d Lave hiied the contractois listed below who have the following wa�kess'comp�sation polices: s�t uae: � d�s: �1F: M �r�: �- �]': oYre 9� Fa�sl�+eene evea6e n�eqyd odv Sx6r 2SA dMGL 1ffi n�kad b tYe h�IW dviNd pstl9e da fe�M SI.SMM Whr - eueyanlsptiwwmtnwdae3vYpaaltln6tTieG'ssCa31WW6RK6RDSAada�6ei(SI6l.i�adryaplst�e�lodvshWtWa -. apy�ttY6 Maeeant my he tWwudM N Ne Omce dLve�plY�e Ktlie DIA RrowMge vW�nIM�. /do ha�eby certfy ler NYe petna m�lP�olDad�7'tN�t1Ye i�forarltaa provlded abeve B axe rwd asnrct �� r�.�/�� .� � � I �-alo�( P�� rQ.� �� ,pti Phone# �R- �a�-�u u7 e�dYaeeeaty d.wwrkertWunvhe��9�7eYwa�i1 dty x ts�rn: perdfAome p ^'�no�e De�t ❑ehed Niw�!Raqese b tM�� 4dc�n'�Omee ❑tleaMA D�t mat�ct Pa*ru. PM�e M; ❑01ra tm�a sm�.mm) THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-002 FEE: $200.00 T7vsistoCertifythat ('niagk Tnr d/h/a Tclanrl Tan 23D White's Path. South Yarmouth, MA IS HEREBY GRANTED A LICENSE For COMNNIERCIAL TANNING FA('ILITIE (105 CMR 123 0001 FOUR(4) TANNING DEVICES �s�eimit�s�a�ted�c� fi�r�m��with Article VI of�he Sanitm�Code of The Coaunonweatth of Messachusetts,and s er ess sooner suspen or revo ed D��i6 zooa soaxD oF�a,�.�: Be.�j�«,r•.��f, l�'ozdok,i41.�, � P�� v� e� Rode�t 4. B� Gle3k �$� R R.N. Bruce G. Mu�phy, ,RS.,CHO Director of Health . _ �dN—oo� � �� ;5 �, a �� - � �� YAR�p TOWN OF YARMOUT FE81g2004 � � HEALTH DEPT. ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-445 ��,[[[ � M/1TTACXfES � ✓�/nC/ �+k��owe�� Telephone (508) 395-2231, Exc 24] — Fax(SOS) 39&2365 �� BOARD O F H EALTH �� s ��' SUN TANNING ESTABLISHMENTS APPLICATION FOR LICENSE/PERMIT -2004 ' � � `��-1-�(�/�(? Name of Establishment: �S�� t �Y1 Te! hone No.: . Address•,�� 1-�� C�Q�' V'� � ��a S 7 h �l�.ss - Mailin¢Address (If different from above): '�— Owner/Corporation Name: Telephone No.: Owner/Co ration Address: Manager's Name: � a�^t��/ c �o TeleQhone No.: Manager's Address: � � 1� Ps�� G�W�6 � ' / w�� . Under Chapter 152, Sec. 25C, subsection 6,the Town of Yarmouth is now requaed 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. T6e attached State Worker's Compensation Insurauce Affidavit roust be completed and sigued. Town of Yarmouth ta�ces and liens must� �aazd prior to renewal or issuance ofyour pemuts. Please check appropriately if paid: yes �/ no LICENSE/PERMIT REOUIRED: Fee: $50.00 per device #OF TANNING BEDS:� #OF OTHER TANNING DEVICES TOTAL� TANNING DEVICE INFORMATION: �Manufacturer Model Number Serial Number Tyae of Bulb a �l� I`� Notice: PERMITS RLJN ANNiJALLY 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 reopening. DATE: a� SIGNATURE: �q.–�� 10/03 �'� Printea on � Recycled Pacer . _ � The Commonwealth ojMossachusetls s : Departmen! of Industrial.-Iccidents ; 0/Acso//aresrlDsahis 600 Washington Slreet Bosron. Mass. 01111 " Wbrkers' Compensation Insurance Aftidavit Aoolicant informati�on-�: P►esi�PItI1VTTes��a nami�. 2� �/St-1 ` �rf1�/�l�a . . . locmion: � _ � �On!\ U^ ' � �� U �L��J��a I� �1/"�� . ehone N � (�d — � �� I a a homeowner penortning ail work myself. � I am a solz proprittor_r.,', ha�e no one «orkin� in am capacin� � I am an employer pro�idin� workers' com ensation for my employees workine on this job. comnam� aame: /o�,or.�� Ar\ l�hL.' � � �JAress:�C� ��P_� A� titr�D3� �-1 ��YV�.a J�1"� Y�(`��Y ` ohone N: ��`'� —Y��-� I � - i n k � I �m a sole proprietor. general contractor. or omeowner ' c!e onel and hace hired the contracrors listed below ��ho ha�e thz follo�cin; �corker;' ;ompensation polices. L9.�V3.Cvname• � � � �)d��l • . ad d resr — LjSr �'�f��YhssV �"'" V Y`K ehonep• . \ � � — ��3 � � �6 b insur�ncc co oeliev# eomnanv name• P/ � �� l 2�T . . . iddrcs•• — tjjy�`�bJ�— "\P rlMr 9L-� �Y�' phoee M: � . . inenrwn�n rn_ � p011ev M 1 F�ilure to seeure covente�s required under Sectlos SSA of MGL IS3 n�lad a t6e i�po�ido�o(tridW peultln ot�0�e ap ro 51300.00 a�d/or one yan'imprisoameet u w�ell aa eiril pendHa io t6e form ot�STOP WORK ORDER��d a Os ofS100.00�dfr K�imt sa [��denu�d tY�t a eopy of tAy saument m�y be fon.�rded to�he Olifee of InvaNQ�tlom otthe DtA tor eoverate rerilfptlo�. � l dn hereby certij}•under the pains and ptnalties ojpery'ury�hat tht injormation provid�d abovt is trut and eor►eet �c� o �� _ Signaturc .- �� Date �� (T�'�_ Print name 1h+one M oRcial use onl�� do not wri�e in�his ana to be tompleted by eity or towa ollltiil city or rown: YA��DT$ _ permiNieenae a n8uilding Departmeu� pl,ie�nsio;Bo�rd p cheek if immediate response ie r�quired 261 �Seleetmen'�Oflice - �Hu1tA Dep�nment � rontact person: phone N:_ �508� 398—T231 eEt. nOther THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-006 FEE: $200.00 This is to Certify that icland Txn„ inc 23D White's Path, South Yarmouth, MA IS HEREBY GRANTED A LICENSE For ('n1�Il�iERCIAL TANNING FACILITIES (105 CMR 123 000) FOUR(4) TANNiNG DEVICES e�icpsi�es��m��1�004��e�ss�son�eresv�i�e��tev�k�ode of The CotnmonwealUt of Massachusetts,and ��h a. 2ooa sonxD oF xE.ar,�: Bwy�.$. �do.r, M.95. G'l.at�►�.� PE�i�%Mr�olt, �/ics�ra'�u�C Ro�sR�4. B�orws. � d�a�C �. R./�. +�lf�d�, R.N. % ruce G. Murphy, PH .,CHO Director of Health