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S M EAD®
KEEPING YOU ORGANIZED
No. 12534
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Date:-7-10/`�
TOWN OF BARNSTABLE
,TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS:
BUSINESS LOCATION: CgT("InC k Cl` �� ��n�FrJ MA INVENTORY
MAILING ADDRESS: TOTAL A UNT:
TELEPHONE NUMBER: 0 � --Go Si 9 ��-, - 509 Ze'o 07 S 1
CONTACT PERSON: H Nr CIn i'✓r�0.f1 i\n �-r0.� E
EMERGENCY CONTAC TELEPHONE NUMBER: 5 O g 3(oG MSD ON SITE?
TYPE OF BUSINESS: 2 —\ I\) Q
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach) �V 6
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash `
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your In Business certificates [cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
_ DATE: O}- Z l�� Fill in please:
N �1 .91 � 1 APPLICANT'S YOUR NAME/S: r ' M
2 3 Z
>w= BUSINESS YOUR HOME ADDRESS: S 14 r Cia c 1c c ✓ S C' G M-b
f 508 3601 CIS
,. 1A �
TELEPHONE # Home Telephone Number 5 O
6- Uri
NAME OF CORPORATION: TYPE OF BUSINESS i^t
NAME OF NEW BUSINESS— P iYT cv��C�C PfJ i N A- N(�, —
IS THIS A HOME OCCUPATION? A YES NO `r J`�\C �MAP/PARCEL NUMBER 5 [Assessing)
ADDRESS OF BUSINESS Crec_k Gr CC z 63 Z
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this tbWrn:'
1.. BUILDING COM SIO ER'S OFFI EMPLY
This individ I h s n i o an pe mi require ents at pertain to this type of busineRU ST AOND RE ITH HOME
FOCCUPATION
LATu hori Si * COMPLY MAY RESULT IN FINES.
M EN S:
D F HE TH must OMP._�LY W" Y.
2. BOAR t h ain to e of business. -
This individual has been informed of the er HAZARDOUS MATERIALS REQ,A.TIONS
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME & ADDRES/SS
OWN ER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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