APPLICATION FOR A
LICENSE TO OPERATE A TANNING FACILITY
*A copy of your customer
consent form and your operating and safety procedures needs to be submitted
with this application *
Name of
Facility______________________________________________________
Address_____________________________________________________________
Phone
Number_______________________________________________________
Days & Hours of
Operation____________________________________________
Address_____________________________________________________________
Number of Tanning
Booths________
Booth # 1. Manufacturer__________________ Model Year________________
Model #__________________ Serial #_________________________
Booth # 2. Manufacturer__________________ Model Year________________
Model #__________________ Serial #_________________________
Name and address of the tanning
device supplier, installer, and service agent:
___Please include a copy of the
consent form to be used by the facility in fulfilling the requirements of 105
CMR 123.012 (D 2 & 3)
___Please include a copy of the
operating and safety procedures to be followed in the operation of the facility
and tanning devices.
___Training certificate to be
attached (unless we have on file).
Permits not to be issued without proof of training by an approved
source.
I have read the Regulations and understand my responsibilities under the law;
yes_________________no__________________*
*If no, please call this office immediately
Signature of Applicant ______________________________________________