HomeMy WebLinkAboutAttraction Salon - 12/31/2009This is to certify that:
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Tanning Salon Permit
LORRAINE A. GALANTI
Is hereby granted a permit for: ATTRACTIONS SALON
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit Number: 4
This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires on
June 30, 2010 unless sooner suspended or revoked.
Fee: $25,00 plus $5.00 per device =
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
$30.00
0
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Tanning Salon
PERMIT NUMBER: 4 _
I hereby make application for a TANNING SALON PERMIT, which expires on June 30th of each year.
BUSINESS NAME
BUSINESS ADDRESS:
ATTRACTIONS SALON
12 PRATT STREET
CITYITOWN: MANSFIELD STATE: MA ZIP: 02048
OWNERIOPERATOR: LORRAINE A. GALANTI
BUSINESS PHONE: (508) 339_7001
BUSINESS FAX:
FEDERAL IDISS NUMBER: 680-668-909 __
HOURS OF OPERATION:
TYPE OF DEVICES: 1 BED
NUMBER OF DEVICES: 1
FEE: ($25.00 plus $5.00 per unit) _ $30.00
SIGNATURE:
DATE:
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
TAX CERTIFICATION FORM
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.
Sign ure of Individual or Corporate Name
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"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this 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 Massachusetts General Law
Chapter 62C, section 49A.
R:\Hm1th\Jane's DocumemS\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwrv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:��j�1O/
Phone
Are you an employer? Check the appropriate box: BusinessType-(require(F):
1. ❑ I am a employer with employees (full and/ 5. Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. e I am a sole proprietor or partnership and have no I, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
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]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care r
with no employees. [No workers' comp. insurance req.] 12.U✓ Other � G I i ) G it) IA\
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
-*If the coapomte offices have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' conrpensatioit insurance for ray 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).
Failure to secure coverage 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, tinder the pains and penalties ofperjury that the information provided 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 Person:
www.mass.gov/dia
Phone