HomeMy WebLinkAbout1676 FALMOUTH ROAD/RTE 28 - HAZMAT "Zo?_o 0 3 Y:
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Number Fee
1247 THE COMMONWEALTH OF MASSACHUSETTS $so.00
Town of Barnstable
Board of Health
This is to Certify that Coachlight Carpets, Inc.
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/ 7fSR I680 almouth Road, Centerville, MA
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Is Hereby Granted a License
For: Storing or Handling 26 - 110 gallons of Hazardous Materials.
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Restrictions:
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This license is granted in conformity with the Statutes and ordinances relating there to,
and expires 06/30/2021 unless sooner suspended or revoked.
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JOHN NORMAN
DONALD A.GUADAGNOLI,M.D.
07/01/2020 PAUL J.CANNIFF,D.M.D.
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
Town of Barnstable
Inspectional Services BARNSTABLE
QF WtN. TnOtE•CEATEtV-CONn•M1—]S
Public Health Division n^u1aI5Yll5.9�"E0.YILL••1�?Si&1ANST4BiE
1639-2019
1 �� 1 Thomas McKean, Director t .
F ems` 200 Main Street, Hyannis,MA 02601 F
Office: 508-862-4644 Fax: 508-790=6304
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE '
HAZARDOUS MATERIALS
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108,
HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS
GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS
JULY 1 st—JUNE 30th).
APPLICATION FEES /
CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 L�' � pG�
_ CATEGORY 2 PER-MIT 1.11.—499 Gallons:_ _ _ $125.00 ❑ 1
CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑_ '2-1 L4PU
*A late charge of$10 00 will be assessed'if payment is not received by Ju!Y 1st.
1. ASSESSOR'S MAP AND PARCEL NO.
2. IS THIS A PERMIT RENEWAL?_YES_NO. IF YES,SKIP QUESTION 3.
3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS
ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF
GREATER THAN HOUSEHOLD QUA1NTITIES(25 GALLONS)? YES NO.
4. FULL NAME OF APPLICANT:
5. NAME OF ESTABLISHMENT: ��A�► 911'� n A 3'h c
6. ADDRESS OF ESTABLISHMENT: �� l�i� �mv�Tel �Q wfe .11 f�Z Z
7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE:
8. TELEPHONE NUMBER OF ESTABLISHMENT: �49-P 7 7 d ZS4
9. EMAIL ADDRESS: &Ac iV 1vtonn e s pq 400 turrn
10. SOLEOWNER:_,p(-YES_No IF NO,NAME OF PARTNER:
11. FULL NAME,HOME ADDRESS,AND TELEPHONE# OF:
CORPORATION NAME
PRESIDENT 54en4 11 3 /4s A/v fir .e A iMh 01,6jr2 77q 9,76 bZod
TREASURER
CLERK
. 12. IF PREPARED BY OUTSIDE PARTY: _
NAME: TELEPHONE#:
COMPANY ADDRESS EMAIL:
SIGNATURE OF APPLICAN DATE
Q:\Application Forms\Haz Mat Appli Draft Jan20l9.docx