HomeMy WebLinkAboutSun Kissed Tans - 12/31/2012Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Tanning Salon Permit
This is to certify that: AMY SOFIA KAPOUTSOS
Is hereby granted a permit for: SUN KISSED TANS
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit Number: 5
This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires on
June 30, 2013 unless sooner suspended or revoked.
Fee: $25.00 plus $5.00 per device =
BOARD OF HEALTH
$45.00
MichaeCHeaCey, Chairman
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Tanning Salon s�
PERMIT NUMBER: 5
I hereby make application for a TANNING SALON PERMIT, which expires on June 30th of each year.
BUSINESS NAME: SUN KISSED TANS
BUSINESS ADDRESS: 270 NORTH MAIN STREET 0'�
CITYITOWN: MANSFIELD STATE: MA ZIP: 02048
OWNER/OPERATOR: AMY SOFIA KAPOUTSOS
BUSINESS PHONE: (508) 339-2433
BUSINESS FAX: _
EMAIL
FEDERAL ID/SS NUMBER: 010-66-9473
HOURS OF OPERATION: MON-FRI 11-7 SAT 10-4 _ } �} j � � 1 D
OI
TYPE OF DEVICES: 2 STAND-UP UNITS; 2 BEDS
NUMBER OF DEVICES: 4
FEE: ($25.00 plus $5.00 per unit) _ $45.00
SIGNATURE,: 9 ---
DATE: s
1
r
Please make appropriate changes, sign, date, and enclose check payable to Town of Mansfield.
Mail to: Board of Health, Town of Mansfield, Six park Row, Mansfield MA 02048
I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
tl_ >—r' e—tf , J
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the certification clause is signed by
the applicant.
** Your Social Security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or tax
payment obligations. Licensees who fail to correct their non -filing or delinquency
will be subject to license suspension or revocation. This request is made under
the authority of Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information CC� �/ Please Print Legibly
Business/Organization Name: SON 11 1 55 0 LAN J
Address:2- ®�Z N -_ I I N STV U �i l S () i rE ) 0 1
City/State/Zip:
2
Are you an employer? Check the appropriate box: I
B t ess Type (required):
1. ❑
I am a employer with employees (full and/
5•P-Patail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.
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.
8, ❑ Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11. ❑Health re
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. rNo workers' comp, insurance req.]
12. Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inftjmlation. V -
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensa[i n policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failuro to secure cover age as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provide above is true and, correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone
Jane Doucette
From:
Amy Kapoutsos <sunkissedtans2433@gmail.com>
Sent:
Thursday, August 09, 2012 12:22 AM
To:
Jane Doucette
Subject:
Re: Application for Tanning Salon
Hi Jane,
I am so sorry for the inconvenience. I do not have any employees, it is just myself
listed on the insurance and therefore I do not have workers compensation. Any
forms at all you may need still I can get in touch with my Insurance Agent and have
her or myself get the paper work over to you ASAP. bo you need me to come in to
fill out the state form? Let me know what is easiest and I can try to work something
out for tomorrow if need be and anything I may need to take care! Thanks so much
Jane and I apologize once again for any trouble or hassle I may have caused. Talk to
you soon!
Sincerely,
Amy
On Wed, Aug 8, 2012 at 9:11 AM, Jane Doucette <Jdoucettemansfieldnia.com> wrote:
Hi Amy, I need to know if you have employees and therefore need workers' comp insurance. You did not
check off any of the boxes on the state form. If you are required to have the insurance, I will need to see the
workers' compensation policy declaration page showing the policy number and expiration date. I can not
process the application until I have the information and your license expired on June 30, 2012.
Sun Kissed Tans
27o North Main Street
Mansfield, MA
02048
(508)339-2433
www.tanskt.com
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