Bell at Salem Station Pool Permit Application 5-20-2020 �
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-36 CITY OF SALEM
BOARD OF HEALTH lu
CITY OF SALEM,AWS ACHUSETTS
&»RD oi.HL.,maT1 Pub&HeaUh
120�/:i.SF1ID1C;1'O�S'I?tI:li 1;41"FLOOR 2I nr2.TromoM NVEm".
n..[..(978)741-1800 FMX(978)745-0343
health rsalem.cam
KLv-1BEIiI EY DRISCOf,L LARRY RAM. D1N,R 5/RIs1Is,('110,(:t>-
NIAYOR HEy�L'1'I i A(il"NT
APPLIOATION FOR PERMIT TO OPERATE A SWIMMING: POOL
LOCATION OF POOL__ I l i .E}�4 �— S y
NAME OF APPLICANT Z C'�7` aq D''l �T��l® L#��_ 74 f C'
MAILING ADDRESS = S7" 6A -
F�MrQrr.
CERTIFIED POOL OPERATOR
Name:JJ,
�� Cert#:�TFL# �- �S46 S f
DATES OF OPERATION(if not annual):_ Coo
DAYS&HOURS OF OPERATION: 1
TYPE OF POOL
Public _
Semi-Public
Spedal Purpose --
Square Footage_ 1 f rt � � sf Volume 3 e? gallons Bather Load
FEE: $210.00 for year-round pools �140.00 for seasonal $40.00 Non-Profit
(Please pap total with one check pays a to a City of Salem)
This permit is not transferable and must be reissued upon change of ownership.
In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 63C,Section 49a,I certify under the pains and penalties o£perjury that I,to my best Iomowledge and belief
have f led all s e r and paid all state taxes requsred underthe law.
Signaiate Dat
e SS#orFederalldenii5ration Number
Check#JG -!' Ante J f Amount
Revised 512V2017 poop l l.doc