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PERMIT APPLICATION – TANNING FACILITIES
FEE: $110.00
Business Name:
Location:
Owners/Operator of business:
Address:
Town: State: Zip:
The manufacturer, model number, model year, serial number and type of each ultraviolet lamp or tanning
device located within the facility. (Use back if necessary)
Manufacturer: Model Number:
Model year: Serial Number:
Type of Ultraviolet Lamp:
Type of Tanning Device:
Enclosed please find the requirements of 105 CMR 123.000 for Tanning Facilities.
I hereby certify that I have received, read and understood the requirements of 105 CMR 123.000 for Tanning
Facilities.
Signature: Date:
APPLICATION MUST INCLUDE:
1. Signed application with state required workers compensation form.
2. Fee ($110.00)
3. A copy of the consent form to be used by the facility in fulfilling the requirements of 105 CMR 123.000 (D)
(2) and (3).
4. A copy of the operating and safety procedures to be followed in the operation of the facility and
tanning device.
NO LICENSE WILL BE ISSUED WITHOUT ALL REQUIRED FORMS ATTACHED. LATE FEES AND CHARGES WILL RESULT
SHOULD PERMIT EXPIRE PRIOR TO RENEWAL.
Town of Brewster
Health Department
2198 Main Street
Brewster, Massachusetts 02631-1898
(508) 896-3701 Ext. 1120
FAX (508) 896-4538
brhealth@brewster-ma.gov