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HomeMy WebLinkAbout0010 BODFISH PLACE - Health 10 Bodfish Place Hyannis r A= 306-232 wl I i I TOWN OF BARNSTABLE Date: ( / TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: J?C BUSINESS LOCATION: INVENTORY MAILING ADDRESS: /© l3v i7 "A 6 i 1 TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: L/A 2 I DI K' E� o i yzrr t (AA EMERGENCY CONTACT TELEPHONE NUMBER: ., S 7-Z7`j MSDS ON SITE? TYPE OF BUSINESS: p dw-l t-&- 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 ✓" v /4-1£ Laundry soil &stain removers (including bleach) , Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS PP scant igna ure Staff's Initials YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary.signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: 2-o S Fill in please: APPLICANT'S YOUR NAME/S: L.•,4- LQ/h/4�' ilyS�L/v b Lr vixr t/l/a �b BUSINESS YOUR HOME ADDRESS: /�' /30� FrSG,t 84— 1-zi�/nrNr 5 tires¢ o�6e�i.RL' TELEPHONE # Home Telephone Number 5v _ .2�// `NAME OF NEIN¢U$INESS1. .. _. ... i T11YG.. : ........... TYPE OF'6USINESS A / 1Y' 151�FISH HOIVIEiC]GCUPAxIpN? ' YE NO ._ .. . ....,.. .�I.....,.,_. .:•• •:_ . . � _ ., 'MAR/PARCELIVUMBER '(Ass slug When starting a new business there are several things you must do in order to be in compliance with the rules ankaulation 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 h the appropriate permits and licenses required to legally operate your business in this town. (( 1. BUILDING COMMISSIONER'S O E. This individual has of ad of any mit requirements that pertain to this type of business. ut oriz d Signature** COMMENTS: .2. BOARD OF HEALTH MUST COMPLY-WITH ALL This individual has been informed of the p it re uirements that pertain to this type of business. HAZARDOUS MATENALS REGUTATIONS Authorized Signature* COMMENTS: S. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: 1,9111 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH. YOU MUST DO according to 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, 15` FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. - DATE ©C 7 - Fill in please: APPLICANT'S YOUR NAME/CORPORATE NAME BUSINESS YOUR HOME ADDRESS: n�2 1!� � TELEPHONE # Home Telephone Numberhhls. NAME OF NEW BUSINESS 71 car Have you been given approval from the building.division? YES ADDRESS OF BUSINESS F� i AP/PARCEL NUMBER • 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 town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 2. BOARD OF HEALTH This individual has been Armed of the permit r irements t pertain to this type of business: MUST XMPLY WITH ALL HAZARDOUS MATERIALS REGULATIONS ized ignature"" 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: 1 n Date:/D/dP/ � TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 12,4 (j � C �- 4&e�— /O 7300 0 BUSINESS LOCATION: _T INVE T8� MAILING ADDRESS: 56� 1. TOTAL AMOUNT: TELEPHONE NUMBER: 0 7 CONTACT PERSON: e-, t C T--� EMERGENCY CONTACT TELEPHONE NUMBER: �o 022// `g �M5® SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: /(/� C; 'f—r� Fire District: �l �T !� 2/1 Z �_r r-A o N c f d 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 lectrolyte)/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, (including carbon tetrachloride) Lacquer thinners ❑ 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) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initial YOU WISH TO OPEN A BUSINESS? , For Your Information: Business.Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS 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, 15Y FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. Fill in please: Date: -7_ ( / r APPLICANT'S NAME: J . IJ A L L I v = M rr YOUR HOME ADDRESS: O f Ze art . X. BUSINESS TELEPHONE # HOME TELELPHONE#: NAME OF CORPORATION: FID # CO NAME OF NEW BUSINESS, T r A. TYPE OF BUSINESS A l 1,7-1 Co- IS THIS A HOME OCCUPATION?.-. YES NO n ADDRESS OF BUSINESS A9 (3 n D Fl IsC Pz. 1-4�� "/V/ � MAP/PARCEL NUMBER3U ­'W (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is 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 town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of-business. Authorized Signature" lb COMMENTS: MUST COMPLY WITH ALL 2. BOARD OF HEALTH NAZ4RDOUS MATERIALS REGULATIONS This individual has b informed of the permit requirements that pertain to this type of business. L .�ryiyj 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: l / TOWN OF BARNSTABLE Date:/� 0 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: �/y'/S �. �,/ INVENTORY MAILING ADDRESS: /to ano c TOTAL AMOUNT: TELEPHONE NUMBER: : -7,2 7-7 CONTACT PERSON: ir�/,�� EMERGENCY CONTACT TELEPHONE NUMBER: .Sew MSDS ON SITE? TYPE OF BUSINESS: _2/9 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) 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