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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF BREWSTER
BOARD OF HEALTH
RENEWAL APPLICATION FOR LICENSE TO OPERATE A RECREATION CAMP, OVERNIGHT CAMP OR
CABINS, MOTELS AND TRAILER COACH PARKS
This license is renewed/issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts
relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said camps or cabins so
licensed as adopted by the Board of Health, and expires on December 31st of the next year unless sooner suspended or
revoked.
If all information applicable is correct, please sign and return to the Health Department with FEE and the WORKER’S
COMPENSATION INSURANCE AFFIDAVIT FORM. Should corrections be needed please do so.
TYPE OF LICENSE
MOTEL ($50.00) MOBIL HOME PARK ($50.00)
CAMPGROUND ($50.00) RECREATION CAMP ($50.00)
TOTAL DUE: $50.00
Business Name: Telephone:
Operator: Location:
Address
APPLICABLE INFORMATION MUST BE FILLED IN BELOW
Number of Campers expected: Number of staff:
Maximum number of Campsites:
Safari Fields:
Self Contained Units:
I HEREBY STATE THAT ALL ABOVE INFORMATION IS TRUE OR HAS BEEN CORRECTED
Signature of Agent/Operator
Town of Brewster
Health Department
2198 Main Street
Brewster, Massachusetts 02631-1898
(508) 896-3701 x 1120
FAX (508) 896-4538