Pool permit 2012 t
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Swimming Pool Seasonal Permit
DATE PRINTED: 05/25/2012
ESTABLISHMENT NAME: Kernwood Country Club Pool
File Number:BHF-2004-000193 1 Kernwood Street -
Salem MA 01970
LOCATED AT: 0001 KERNWOOD STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
SWIMMING POOL- BHP-2012-0449 May 25, 2012 Sep 29, 2012 $140.00
SEASONAL
Total Fees: $140.00
PERMIT EXPIRES September 29, 2012
Board of Health
Page 1
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r CITY OF SALEM, MASSACHUSETTS
BOARD OF HEAL,tH
120 WASHINGTON S1RI717r,4TM'FLOOR
KIMBERLEY DRISCOLL TEL.(978)741-1800
FAX(978)745-0343
MAYOR LRAMDIN@SAI,EM.COM
LARRY RAMDIN,RSAREHS,CHO,CP-FS
HEAut-I AGENT
2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL � P yrl loco l W C( v2 dry C(v &
NAME OF APPLICANT �1vhWOOJ (OuvL+ y C,ru_ TEL# 99S 75/5-I--/o
rel ADDRESSe rwood St, 6M HA-- 01,G z r)
CERTIFIED POOL OPERATOR
Name: bouILa.) A1 n( L cert4:6/-P1g3A TEL#
DATES OF OPERATION(if not annual): ka� ;L,(, )-61 -1- - 3, SLG 11
DAYS&HOURS OF OPERATION: kc, r\ - ,Su n 1 I avvl
TYPE OF POOL
Public
Semi-Public
Special Purpose
FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit
(Please pay total with one check payable to the 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 of perjury that I,to my best knowledge and belief,have
filed all state tax returns and paid all state taxes required under the law.
Kae�t,z� S� aS� /�_
Signature Date SS#or Federal Identification Number
Revised 5/23/11 poolappil.doc Check#Date A
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