HomeMy WebLinkAbout0030 MAIN STREET (HYANNIS) - Health •
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TOWN OF BARNSTABLE Date:&
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS:
BUSINESS LOCATION: / 7`�,_ �� INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: J �(� ' /Z? MSDS ON SITE?
TYPE OF BUSINESS: j2A Wfi
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
B 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 I (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
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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-ta-0p r cr 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 02 60 1. (Town Hall) and get the Business Certificate that is
required by law.
DATE: - Fill in please:
5:•as'r: ,, .' :a_' YOUR NAME/S: ' f
:x; �:s;� •,' ;tt� `� APPLICANT'S
}•'c:�!��IY°G#iv?�:�i �� ;t•' �;a;:w BUSINESS
YOUR HOME ADDRESS:
p_:.:,i�•f^I:• .ter la Jq... •;Ytr_�:�
I'"SL{'•.hi`fisYi!' ,;•-
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�i:'�;�•'� ='r TELEPHONE # Home Telephone Number
ry+.: dF;•:! .'4�L41i45�1r� �� E-MA I L:
NAME OF CORPORATION: i 11r—
NAME OF-NEW BUSINESS J d TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? YES NO '
ADDRESS OF BUSINESS. - - - — AP/PARCEL NUMBER -._... --- - ._ (Assessing)
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 yo.0 have the appropriate permits and licenses,required to legally operate yo'`�ur bminess in this town.
1. BUILDING COMMISSIONEF11S OFFICE MUST COMPLY WITH HOME OCCUPATION
This individual has been for d of any p requirements that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO
COMPLY MAY RESULT IN FINES.
Authorized Signa re** C'
C MMENTS: v /^k �ry
L1�4-P
2. BOA D OF HEALTH
This individual h s �e�n informed f e requir ents that pertain to this type of business.
MU.ST COMP._LY WjTH AlL,
Authorized Signature** kfAZARDOU _MA•TERIALS RC�ULAdIS
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: .
'r TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE I1:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
r i,,
Owner &%&16ATenant IQ&r- A 3rcr'
Address & v Mph Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities e✓
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities /
6. Heating Facilities V
7. Lighting and Electrical Facilities /
8. Ventilation V
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements a
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
P ht
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Person(s)Interviewed In pector
If Public Building such as Store or Hotel/Motel specify here ��� � �
Hoaas&WARREN,INC.
4:221PM STABLE BOARD OF HEALTH N0.682 P.22
XRV
Assesoor's office (1st Floor)
' Asaaguorto Hap and Parcel #
Building Department (4th Floor)
Zoning
INSPECTION FEE 66
RE-INSPECTION FEE $15.00
Request For A Housing inspection For Certification Under the
X% Rental voucher P am i
Your Name C,
Affiliation (Circle One) Owner R al Estate Agent Tenant
Your Address_ �c�.��- (► , !'f'vj J71' L�
Telephone Number (Day) ,_(Night) �.
Address of Pro arty ere Inspection is PAHMeste
Unit/Apt.#
Fame of Owner l
Address
A0 /J) S f.
Mailing Ad"dress (it different)
Telephone Number (Day)2 —6-/GCJ (Night)
Will there be any children under the age of six (6) Mwhbe occupying the rental unit? (circ]!e one) Yes Wasthe dwelling constructed prior to 1979? Yes
OFFICE USE.-ONLY,
Certification
The dwelling, dwelling up t, or rooming, unit located at
3 stc.�fi r� M azho was inspected on
i2-3 0 2 y `�--e Health
Inspector for the Town o Barnsta` le and was found to be in
compliance with the provisions contained within 105 CMR
410.00, State Sanitary Code IIi Minimum Standards of Fitness
for Human Habitation. Havever, this certification does not
include a determination as to whether this unit contains any
load paint because undor 760 ClRt 69.02 Massachusetts atal
Voucher Program., a separate lead paint inspection must be
conducted.
Inspector's Si nature
Date
II