HomeMy WebLinkAboutEric Allen Salon - 12/31/2007COMMONWEALTH OF MASSACHUSETTS
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD, MA 02048
TANNING SALON PERMIT
This is to certify that
Eric Allen
Is hereby granted a permit for
ERIC ALLEN SALON
This permit is granted in conformity with the Statutes and Ordinances relating
thereto, and expires on June 30, 2008, unless sooner suspended or revoked.
Fee: $25.00 plus $5.00 per device = $35.00
Permit No. 3
Dr. Raymond Martin, Chairman
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
APPLICATION FOR TANNING SALON
I hereby make application for a TANNING SALON PERMIT, which expires on
June 30°i of each year.
BUSINESS NAME:
BUSINESS ADDRESS:/
TYPES OF DEVICES:
TELEPHONE NO.:sC/ti �s
FAX NO.:
FED ID/SS NO.: —z
I»IN�LIYa�(��
FEE: $25.00 plus $5.00 per unit =
SIGNATURira�
DATE /✓/ /
I certify under the penalties of perjury that 1, 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)
0
By., Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will notbe issued unless the certiffication 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 -tiling 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.
I am a sole proprietor and have no ogb Business e: � j Retail [J Restaurant/Bar/Eating -Establish
working in any capacity. [ Office ❑ Sales (including Real Estate, Autos etc.)
[ am an employer with ._L employees (full & part tithe). F-] Other
am an employcUrroviding workers' compensation fqr my employees working on this job.
I I am a sole proprietor
compensation polices:
contractors listed below who have the following workers'
ec J
✓ _ �� ���
insurance co. olio
company name:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine lip I
one yearn' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I
copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification.
!do hereby certify on der the pains and pen aides ofpedury that the Information provided above is true and correct
Print name
official use only do not write in this area to be completed by city or town official
city or town:
❑ check if immediate response is required
contact person:
(.,ixd SVL 2003)
_ perrdfNcensc # ❑Bultding Department
❑Licensing Dowd
❑Selectmen's Office
[]Health Department
phone#; ❑Other
that a
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the `law' or if
you are required to obtain a workers' compensation policy, please call the Department at the number listed below.
.✓'*fi'-.,,i."�',F'�e,+a`w"r.. -ca sx �T '} �' r..a-?-_ "'r"r}.<�z�'s'-;s.,� }4iE
a
ndwta .G..,v,-�.a�.�v.. ,. _.�E'v._.t.... "���E�.,..City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permittlicense number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,
The Commonwealth Of Massachusetts
Department of Industrial Accidents
81 iceolhrveovallons
600 Washington Street, 7�s Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 ext. 406