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SOLAR ELIPSE TANNING 2011-TANNING - ESTABLISHMENTSS71-. s uv l c t//!/ it/4 y`, E l2 M l% u DATE PRINTED 01/03/2013 �'P r E y 3 ems # € .g in ` sY'r"e"Y ESTABLISHMENT NAME: Solar Ech se Tannin` (/2 z b File Number BHF 2004 000339 �"` ra 132 NOrth Street "`" t _. ,> IA Salem x� MA 01970 r 4 LOCATED AT 0132,N STREET=x� .� > s ' SALEM, MA 0197It 0 ; Permit Type*�'. `Peruut No: Permlt.Issued <Permi[ Eiinres m; - Fee Restrictions / Notea _ <SIJNT'AN > : °s- BHP 2013 0349 Jan 1, 2013 Dec 31;120131 $140 ., . ESTABLISHMENT J s Totai Fees $140 00 r gc Z kk aE F If $_ :. �.s4rca§& 29'3e� tz .nz -'�'' eR gr-.�� r �. a?hj '•' 'ei'. yr< ^+ - "" .. �. -oi=.y `'x'V.^'y 6 L'. ' �, e" =a • ^ act.- �+s, 1�, -,�-_ z: �, '' tl *14 'PERMIT EXPIRES December 31,,2013„x f e'' Board of Heath` _ '� $ r. �5, ,3 r '�° -:. ,a e, -11 �op .5�' Er7 r ' , -rz. ±. ' '# ; .- `"` Page 1 5r4,1 KIMBERLEY DRTSCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"" FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 Iramdinnsalem.com IV1PCiK�1'11 Prevent. vem. Promote. Pra(cei, LARRY R NIDIN, RS/RETIS, CHO, Cp-(S FItll\ rl-I AGENT TANNING FACILITY PERMIT APPLICATION Business Name: 5060 F_AiD6e, Phone 01 8-iy4 8853 Bus. Address: \'3 a f�c,2_J:6 5 E- Salem MA. 01970 _ Owner(s)Name:__R,r.n,Q_. _2crDcr Phone# Owner's Address: 8\ Cbr\rnr.,, Q,, �c_ RA Ly nn hA� G\GUti FEE: $140.00 (MAKE CHECK PAYABLE TO — CITY OF SALEM) List the manufacturer, model number, model year, serial number (if available) and type of each ultraviolet lamp or tanning device located within the facility. (if additional space is needed, please use the back of this application.) Mass. Electrical Code Article 90-6: Factory installed internal wiring or construction of equipment must be listed by a qualified electrical testing laboratory (U.L., E.T.L, or equivalent). This application must be accompanied by a check the following information: *name, business address of the tanning device supplier *name, business address of the tanning device installer *date of installation for each tanning device *name of service agent *copy of consent form used for patrons under the age of 18 (105 CMR 123.003 D) *copy of the operating and safety procedures to be followed in the operation of the facility and tanning devices I have received a copy of 105 CMR 123.000: Tanning Facilities I hereby state that I have read and understood the requirements of these regulations. 1.2 /1 7 /1 �-- Sigmture of Applicay Date For Hoard of Health use only Suntanappll l.doc updated 523/11 Check date: /I// / Check #: 56la2 Ec k p -<;t OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853 PAGE 10F 2 BED # 1 FUTURE SUN ROOM MANUFACTURER: AUVL MODEL: FUTURE SUN HP SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/27/2004 SERVICE AGENT: DEREK HENTCHEL BED # 2 MARTINI ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: 2246 MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED #3 LIGHTSTREAM BOOTH MANUFACTURER: CREATIVE MARKETING MODEL: LIGHTSTREAM SERIAL NUMBER: LS3322 MODEL YEAR: 10/2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/2002 SERVICE AGENT: DEREK HENTCHEL BED # 4 TUSCANY ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED # 5 ORBIT ROOM MANUFACTURER: DR. MULLER MODEL: ORBIT 44/4 SERIAL NUMBER: 00321 MODEL YEAR: 1997 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/1997 SERVICE AGENT: DEREK HENTCHEL BED # 6 STARSHIP STAND UP UNIT MANUFACTURER: CREATIVE MKTG MODEL: CYCLONE 55 LAMP SERIAL NUMBER: 0681 MODEL YEAR: 2000 SUPPLIER: FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 05/2000 SERVICE AGENT: DEREK HENTCHEL BED # 7 SOLART ROOM MANUFACTURER: ACN MODEL: SOLART 52/5 SERIAL NUMBER: MODEL YEAR: 2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/2002 BED # 8 MYSTIC TAN MANUFACTURER: MYSTIC TAN MODEL: MYSTIC TAN SERIAL NUMBER: 13695 MODEL YEAR: 2003 SUPPLIER: MYSTIC TAN INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 07/2003 SERVICE AGENT: RUSH WAGHORNE Sol - ��1•. OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853 PAGE 2 OF 2 BED #9 LEG TANNER MANUFACTURER: ULTRASUN MODEL: LEGACY SERIAL NUMBER: 4215 SERIAL NUMBER: MODEL YEAR: 2003 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/2003 SERVICE AGENT: FUTURE INDUSTRIES ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 SOLAR ECLIPSE TANNING SALON RELEASE FORM Name: Home Phone: Address: Cell Phone: City, State, Zip: Email Address: Date of Birth: Skin Type: Light. Med Dark Have You Ever Tanned Indoors Before? Yes No Where? How Did You Hear About Solar Eclipse? What is your Preferred Method of Hearing From Us? TEXT EMAIL PHONE How long has it been since you've had a tan? Have you ever been advised by a Doctor to stay out of the sun? Do you tan easily? Yes No If so, why? Do you have a tendency to bum? Yes No Are you taking any medications which are photosensitive? Do you have any known allergies to sunlight? Yes No Do you have, or have you had during the past 3 months, any skin Do you wear contacts? Yes No eruption or communicable skin disease? Have you ever had a severe sunburn? Yes No Are You Pregnant? If so, how long ago? PLEASE CIRCLE YOUR SKIN TYPE ON THE FOLLOWING CHART: Always Bum, Never Tan Usually Bum, Sometimes Tan Sometimes Bum, Always Tan Never Bum, Always Tan IT IS OUR INTENTION TO KEEP YOU WELL INFORMED ABOUT TANNING. THIS INCLUDES INFORMING YOU ON HOW TO OPERATE THE EQUIPMENT AS WELL AS HOW TO TAN RESPONSIBLY. THE PROPER PROCEDURE TO FOLLOW IN THE TANNING ROOM WILL BE CLEARLY EXPLAINED TO YOU BY THE TANNING TECHNICIAN. PLEASE FEEL FREE TO ASK ANY QUESTIONS OR TO VOICE ANY CONCERNS THAT YOU MAY HAVE AT THIS TIME. OUR GOAL IS TO HELP YOU ACHIEVE THE BEST POSSIBLE TAN, RESPONSIBLY. PLEASE ADHERE TO THE FOLLOWING GUIDELINES WHEN TANNING: 1. AVOID OVEREXPOSURE. AS WITH NATURAL SUNLIGHT, OVEREXPOSURE CAN CAUSE EYE AND SKIN INJURY AND ALLERGIC REACTIONS. REPEATED OVER EXPOSURE HAS BEEN KNOWN TO CAUSE PREMATURE AGING AND SKIN CANCER. 2. PLEASE INFORM US IF YOU ARE TAKING ANY SUN SENSITIVE MEDICATIONS. SOME MEDICATIONS OR COSMETICS MAY INCREASE YOUR SENSITIVITY TO UV RAYS. PLEASE CONSULT A PHYSICIAN BEFORE TANNING IF YOU ARE TAKING ANY SUCH MEDICATIONS OR HAVE A HISTORY OF SKIN PROBLEMS OR BELIEVE YOURSELF TO BE ESPECIALLY SENSATINE TO SUNLIGHT. 3. WEAR PROTECTIVE EYEWEAR. FAILURE TO WEAR GOGGLES MAY RESULT IN SEVERE BURNS OR.INJURY TO THE EYES. 4. I UNDERSTAND THAT IT IS RECOMMENDED THAT I USE AN INDOOR TANNING LOTION FOR MORE POSITIVE RESULTS. 5. MINOR CONSENT. I VERIFY WITH MY SIGNATURE THAT I AM 18 YEARS OF AGE OR OLDER AS REQUIRED BY LAW. IF 17 OR UNDER, A PARENTAL OR GUARDIAN SIGNATURE MUST ACCOMPANY THIS FORM ANY INDIVIDUAL UNDER THE AGE OF 14 MUST HAVE A PARENT OR GUARDIAN PRESENT WHILE TANNING. 6. 1 UNDERSTAND AND HAVE BEEN MADE AWARE UNDER STATE LAW, I AM ONLY PERMITTED TO TAN ONCE IN A 24 HR PERIOD. I HAVE BEEN GIVEN INSTRUCTIONS FOR THE PROPER USE OF THE EQUIPMENT AND I WILL USE IT AT MY OWN RISK. I HEREBY RELEASE THE OWNERS, OPERATORS, AND MANUFACTURERS FROM ANY DAMAGES THAT I MIGHT INCUR DUE TO THE USE OF THESE TANNING UNITS AND FACILITIES. MEMBER SIGNATURE PARENTAL CONSENT DO NOT WRITE BELOW TINS LINE. TO BE FILLED OUT BY THE TANNING TECHNICIAN DATE TAN BED TIME PACKAGE AMOUNT PAID STAFF INITIALS L, SOLAR ECLIPSE OPERATING PROCEDURES 1. CHECK IN TANNING GUEST 2. REVIEW THEIR INFORMATION, CHECKING THEIR AGE, LAST VISIT AND TANNING TIME 3. CHECK THEIR TANNING PACKAGE 4. DISCUSS WHICH BED THEY WOULD LIKE TO USE TODAY 5. RECOMMEND A TAN TIME TO THE GUEST 6. ESCOURT THE TANNING GUEST TO THEIR ROOM AND ENSURE THAT THE CUSTOMER KNOWS HOW TO OPERATE EVERYTHING IN THE ROOM. 7. COMPUTER AUTOMATICALLY WILL SET THE TIMER FOR THE DISSCUSSED TIME. Commonwealth of Massachusetts e a - City of Salem Board of Aea►th Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 SUN TANNING ESTABLISHMENT PERMIT DATE PRINTED: 12/29/2011 KIMBERLEY DRTSCOLL MAYOR LARRY Re11\41)IN, RS/RVI IS, CI 10, CI -FS IIiiAL-H I A(,.ixi, CITY OF SALEM, MASSACHUSETTS BOARD or HFAt: n 1 120 WASn,INGION STRFUG'r, 4'14, Fl ooR F.1_ (978) 741-1800 FAX (978) 745-0343 lrqmditi@salcin.com TANNING FACILITY PERMIT APPLICATION Business Name: Sal" Er_bs A,v,'�� Phone# Bus. Address: 13 t (JojL_i� '5+, Salem. MA. 01970 Owner(s)Name:7pmaka zella.(r,- Phone# q?$•Sc�b•Ooy7 Owner's Address: FEE: $140.00 (MAKE CHECK PAYABLE TO — CITY OF SALEM) List the manufacturer, model number, model year, serial number (if available) and type of each ultraviolet lamp or tanning device located within the facility. (If additional space is needed, please use the back of this application.) Mass. Electrical Code Article 90.6: Factory installed internal wiring or construction of equipment must be listed by a qualified electrical testing laboratory (U.L., E.T.L, or equivalent). This application must be accompanied by a check the following information: *name, business address of the tanning device supplier *name, business address of the tanning device installer *date of installation for each tanning device *name of service agent *copy of consent form used for patrons under the age of 18 (105 CMR 123.003 D) *copy of the operating and safety procedures to be followed in the operation of the facility and tanning devices I have received a copy of 105 CMR 123.000: Tanning Facilities I hereby state that I have read and understood the requirements of these regulations. i.Q/a� Signature of Applicant Date For Board of Health use Suntanappll l.doe updated 523/11 Check date: �E Check #: 9 L/ 6 I 000 ` BODYTAL' K OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853, PAGE 10F 2 BED # 1 FUTURE SUN ROOM MANUFACTURER: AUVL MODEL: FUTURE SUN HP SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/27/2004 SERVICE AGENT: DEREK HENTCHEL BED # 2 MARTINI ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: 2246 MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED #3 JETPOWER ROOM MANUFACTURER: ULTRA SUN MODEL: JETPOWER 17,000 SERIAL NUMBER: 0065471 MODEL YEAR: 2000 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2000 SERVICE AGENT: DEREK HENTCHEL BED # 4 LIGHTSTREAM BOOTH MANUFACTURER: CREATIVE MARKETING MODEL: LIGHTSTREAM SERIAL NUMBER: LS3322 MODEL YEAR: 10/2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/2002 SERVICE AGENT: DEREK HENTCHEL BED # 5 TUSCANY ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED #6 ORBIT ROOM MANUFACTURER: DR. MULLER MODEL: ORBIT 44/4 SERIAL NUMBER: 00321 MODEL YEAR: 1997 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/1997 SERVICE AGENT: DEREK HENTCHEL BED # 7 STARSHIP STAND UP UNIT MANUFACTURER: - CREATIVE MKTG MODEL: CYCLONE 55 LAMP SERIAL NUMBER: 0681 MODEL YEAR: 2000 SUPPLIER: FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 05/2000 SERVICE AGENT: DEREK HENTCHEL BED # 8 SOLART ROOM MANUFACTURER:ACN MODEL: SOLART 52/5 SERIAL NUMBER: MODEL YEAR: 2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/2002 BED # 9 MYSTIC TAN MANUFACTURER: MYSTIC TAN MODEL: MYSTIC TAN SERIAL NUMBER: 13695 MODEL YEAR: 2003 SUPPLIER: MYSTIC TAN INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 07/2003 SERVICE AGENT: RUSH WAGHORNE 4 l BODYTALK OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853 PAGE 2 OF 2 BED # 10 LEG TANNER MANUFACTURER: ULTRASUN MODEL: LEGACY SERIAL NUMBER: 4215 SERIAL NUMBER: MODEL YEAR: 2003 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/2003 SERVICE AGENT: FUTURE INDUSTRIES ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 KIMBERLEY DRISCOU NIAYOR LARRY RAMIAN, RS/RFUS, CI 10, CI' -ISS f4b,Aum Ac;I NT CITY OF SALEM, MASSACHUSETTS BOARD OF HE,,Vrrl-i 120 WASHINGTON STREET, 4"" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 lramdin(a salem.com MEMORANDUM Date: December7, 2011 To: Tanning Facility Establishment Owners From: Larry Ramdin, Health Agent RE: 2012 Tanning Facility Permit (application enclosed) DUE DECEMBER 280 Enclosed is the 2012 Tanning Permit application. A check and the completed application must be received in this office by DECEMBER 28, 2011. You will be issued a $100 ticket for late submission of application and/or fee. Partially completed applications will be considered late and subject to ticketing. A few reminders: • You may not operate after December 31, 2011 without a valid 2012 permit. • The 2011 Tanning Facility Permit is valid only for the owner listed on the application. Change in ownership, requires a new application and a review of the floor plan by the Health Agent. • Any change in the establishment including any renovation must receive prior approval by the Board of Health. • Thank you for your cooperation. �. r RELEASE FORM Name: Home Phone: Address: Cell Phone: City, State, Zip: Email Address: Date of Birth: Skin Type: Light Med Dark Have You Ever Tanned Indoors Before? Yes No Where? How Did You Hear About Solar Eclipse? What is your Preferred Method of Hearing From Us? TEXT EMAIL PHONE How long has it been since you've had a tan? Have you ever been advised by a Doctor to stay out of the sun? Do you tan easily? Yes No If so, why? Do you have a tendency to bum? Yes - No Are you taking any medications which are photosensitive? Do you have any known allergies to sunlight? Yes No Do you have, or have you had during the past 3 months, any skin Do you wear contacts? Yes • No eruption or communicable skin disease? . - Have you ever had a severe sunburn? Yes No _ Are You Regnant? - If so, how long ago? I Always Bum, Never Tan Usually Bum. Sometimes Tan Sometimes Bum Always Tan Never Bum. Always Tan I IT IS OUR INTENTION TO KEEP YOU WELL INFORMED ABOUT TANNING. THIS INCLUDES INFORMING YOU ON HOW TO OPERATE THE EQUIPMENT AS WELL AS HOW TO TAN RESPONSIBLY. THE PROPER PROCEDURE TO FOLLOW IN THE TANNING ROOM WILL BE CLEARLY EXPLAINED TO YOU BY THE TANNING TECHNICIAN. PLEASE FEEL FREE TO ASK ANY QUESTIONS OR TO VOICE ANY CONCERNS THAT YOU MAY HAVE AT THIS TIME. OUR GOAL IS TO HELP YOU ACHIEVE THE BEST POSSIBLE TAN, RESPONSIBLY. PLEASE ADHERE TO THE FOLLOWING GUIDELINES WHEN TANNING: 1. 'AVOID OVEREXPOSURE. AS WITH NATURAL SUNLIGHT, OVEREXPOSURE CAN CAUSE EYE AND SKIN INJURY AND ALLERGIC REACTIONS. REPEATED OVER EXPOSURE HAS BEEN KNOWN TO CAUSE PREMATURE AGING AND SKIN CANCER. 2. PLEASE INFORM US IF YOU ARE TAKING ANY SUN SENSITIVE MEDICATIONS. SOMEMEDICATIONS OR COSMETICS MAY INCREASE YOUR SENSITIVITY TO UV RAYS. PLEASE CONSULT A PHYSICIAN BEFORE TANNING IF YOU ARE TAKING ANY• SUCH MEDICATIONS OR HAVE A HISTORY OF SKIN PROBLEMS OR BELIEVE YOURSELF TO BE ESPECIALLY SENSATIVE TO` SUNLIGHT. 3. WEAR PROTECTIVE EYEWEAR. FAILURE TO WEAR GOGGLES MAY RESULT IN SEVERE BURNS OR INJURY TO THE EYES. 4.' I UNDERSTAND THAT IT IS RECOMMENDED THAT I USE AN INDOOR TANNING LOTION FOR MORE POSITIVE RESULTS. 4 5. MINOR CONSENT. I VERIFY WITH MY SIGNATURE THAT I AM 18 YEARS OF AGE OR OLDER AS REQUIRED .BYLAW. IF 17 OR UNDER, A PARENTAL OR GUARDIAN SIGNATURE MUST ACCOMPANY THIS FORM. ANY INDIVIDUAL UNDER THE AGE OF 14 MUST HAVE A PARENT OR GUARDIAN PRESENT WHILE TANNING. 6. I UNDERSTAND AND HAVE BEEN MADE AWARE UNDER STATE LAW, I AM ONLY PERMITTED TO TAN ONCE IN A 24 HR PERIOD. r I HAVE BEEN GIVEN INSTRUCTIONS FOR THE PROPER USE OF THE EQUIPMENT AND I WILL USE IT AT MY OWN RISK. I HEREBY RELEASE THE OWNERS, OPERATORS, AND MANUFACTURERS FROM ANY DAMAGES THAT I MIGHT INCUR DUE TO THE USE OF THESE TANNING UNITS AND FACILITIES. MEMBER SIGNATURE PARENTAL CONSENT DATE DO NOT WRITE BELOW THIS LINE. TO BE FILLED OUT BY THE TANNING TECHNICIAN TAN BED TIME PACKAGE AMOUNT PAID STAFF INITIALS SOLAR ECLIPSE OPERATING PROCEDURES 1. CHECK IN TANNING GUEST 2. REVIEW THEIR INFORMATION, CHECKING THEIR AGE, LAST VISIT AND TANNING TIME 3. CHECK THEIR TANNING PACKAGE 4. DISCUSS WHICH BED THEY WOULD LIKE TO USE TODAY 5. RECOMMEND A TAN TIME TO THE GUEST 6. ESCOURT THE TANNING GUEST TO THEIR ROOM AND ENSURE THAT THE CUSTOMER KNOWS HOW TO OPERATE EVERYTHING IN THE ROOM. 7. COMPUTER AUTOMATICALLY WILL SET THE TIMER FOR THE DISSCUSSED TIME. Commonwealth of Massachusetts s " City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 SUN TANNING ESTABLISHMENT PERMIT DATE PRINTED: 01/11/2011 ESTABLISHMENT NAME: File Number: B14F-2004-000339 Solar Eclipse Tanning (2) 132 North Street Salem MA 01970 LOCATED AT: 0132 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SUNTAN BHP -2011-0316 Jan 1, 2011 Dee 31, 2011 $140.00 ESTABLISHMENT Total Fees: $140.00 1»I:a0lr111*0MV 31.2011 Board of Health Page 1 ' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4T" FLOOR TEL. (978) 741-1800 KIMBF RLEY DRISCOLL FAx (978) 745-0343 MAYOR DGRFENBAUMQSALEM..COM DAvID GREENBAUM, ACTING HEALTH AGENT TANNING FACILITY PERMIT APPLICATION � Business Name: nJa1ol ccf!1Pa I nrns, Phone#In9 iY'{-PBS Bus. Address: (3�2 - tl rz h S4— Salem. MP 61970 Owner(s) Name: arne-lo, -,- ZLP?�E2- Phone # 9-1 B. S90 -Cc) Owner's Address: �- - W deo,�j , NlA FEE: $140.00 (MAKE CHECK PAYABLE TO — CITY OF SALEM) List the manufacturer, model number, model year, serial number.(if available) and type of each ultraviolet lamp or tanning device locafed within the facility. (If additional space_is needed,. Nease use the back Of this application.)..,_ Mass. Electrical Code Article 90-6: Factoryinstalled internal.wiririg or construction. of equipment must be listed by a qualified electrical testing laboratory (U.L., E.T.L, or equivalent). This application must be accompanied by a check the following information: 'name, business address of the tanning device supplier *name, business address of the tanning device installer *date of installation. for each tanning device *name of service agent *copyof consent form used for patruns under the age of IS (1 05 CYKi23.003 17) *copy of the operating and safety procedures to be followed in the operation of the facility and tanning devices I have received a copy of 105 CMR 123.000: Tannine Facilities I hereby state that I have read and understood the requirements of these regulations. a Signature of Applicant Date - �''I_q',5.: `1 For Board of Health•usey e . <'; 't;p Santana 1 revised 11/14/08 ` Check date: q J /�d� Check # �j BODYTALK OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853 PAGE 10F 2 BED # I FUTURE SUN ROOM ` MANUFACTURER: AUVL MODEL: FUTURE SUN HP SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/27/2004 SERVICE AGENT: DEREK HENTCHEL BED # 2 MARTINI ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: 2246 MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED #3 JETPOWER ROOM MANUFACTURER: ULTRA SUN MODEL: JETPOWER 17,000 SERIAL NUMBER: 0065471 MODEL YEAR: 2000 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2000 SERVICE AGENT: DEREK HENTCHEL BED # 4 LIGHTSTREAM BOOTH MANUFACTURER: CREATIVE MARKETING MODEL: LIGHTSTREAM SERIAL NUMBER: LS3322 MODEL YEAR: 10/2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/2002 SERVICE AGENT: DEREK HENTCHEL BED # 5 TUSCANY ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/27/2004 SERVICE AGENT: DEREK HENTCHEL BED # 6 ORBIT ROOM MANUFACTURER: DR. MULLER MODEL: ORBIT 44/4 SERIAL NUMBER: 00321 MODEL YEAR: 1997 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/1997 SERVICE AGENT: DEREK HENTCHEL BED # 7 STARSHIP STAND UP UNIT MANUFACTURER: CREATIVE MKTG MODEL: CYCLONE 55 LAMP SERIAL NUMBER: 0681 MODEL YEAR: 2000 SUPPLIER:' FUTURE INDUSTRIES INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION:' 05/2000 SERVICE AGENT: DEREK HENTCHEL BED # 8 SOLART ROOM MANUFACTURER: ACN MODEL: SOLART 52/5 SERIAL NUMBER: MODEL YEAR: 2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 4/2002 BED # 9 MYSTIC TAN MANUFACTURER: MYSTIC TAN MODEL: MYSTIC TAN SERIAL NUMBER: 13695 MODEL YEAR: 2003 SUPPLIER: MYSTIC TAN INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 07/2003 SERVICE AGENT: RUSH WAGHORNE RODYTALK OF SALEM TANNING EQUIPMENT LIST 132 NORTH STREET SALEM, MA 10970 (978)744-8853 PAGE20F2 BED # 10 LEG TANNER MANUFACTURER: ULTRASUN MODEL: LEGACY SERIAL NUMBER: 4215 -SERIAL NUMBER: MODEL YEAR: 2003 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/2003 SERVICE AGENT: FUTURE INDUSTRIES ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 ... MIME CCIAIDSB TAMMIEG RMA M RELEASE FORM Name: Home Phone: Address: Cell Phone: City, State, Zip: Email Address: Date of Birth: Skin Type: Light Med Dark Have You Ever Tanned Indoors Before? Yes No Where? How Did You Hear About Solar Eclipse? What is your Preferred Method of Hearine From Us? TEXT EMAIL PHONE How long has it been since you've had a tan? Have you ever been advised by a Doctor to stay out of the sun? Do you tan easily? 'Yes No If so, why? Do you have a tendency to bum? Yes No Are you taking any medications which are photosensitive? Do you have any known allergies to sunlight? Yes No Do you have, or have you had during the past 3 months, any skin Do you wear contacts? Yes No eruption or communicable skin disease? Have you ever had a severe sunburn? Yes No Are You Pregnant? If so, how long ago? PLE YOUR SKINT f Always Burn, Never Tan Usually Bum, Sometimes Tan Sometimes Bum, Always Tan Never Burn, Always Tan IT IS OUR INTENTION TO KEEP YOU WELL INFORMED ABOUT TANNING. THIS INCLUDES INFORMING YOU ON HOW TO OPERATE THE EQUIPMENT AS WELL AS HOW TO TAN RESPONSIBLY. THE PROPER PROCEDURE TO FOLLOW IN THE TANNING ROOM WILL BE CLEARLY EXPLAINED TO YOU BY THE TANNING TECHNICIAN. PLEASE FEEL FREE TO ASK ANY QUESTIONS OR TO VOICE ANY CONCERNS THAT YOU MAY HAVE AT THIS TIME. OUR GOAL IS TO HELP YOU ACHIEVE THE BEST POSSIBLE TAN, RESPONSIBLY. PLEASE ADHERE TO THE FOLLOWING GUIDELINES WHEN TANNING: 1. AVOID OVEREXPOSURE- AS WITH NATURAL SUNLIGHT, OVEREXPOSURE CAN CAUSE EYE AND SKIN INJURY AND ALLERGIC REACTIONS. REPEATED OVER EXPOSURE HAS BEEN KNOWN TO CAUSE PREMATURE AGING AND SKIN CANCER. 2. PLEASE INFORM US IF YOU ARE TAKING ANY SUN SENSITIVE MEDICATIONS. SOME MEDICATIONS OR COSMETICS MAY INCREASE YOUR SENSITIVITY TO UV RAYS. PLEASE CONSULT A PHYSICIAN BEFORE TANNING IF YOU ARE TAKING ANY SUCH MEDICATIONS OR HAVE A HISTORY OF SKIN PROBLEMS OR BELIEVE YOURSELF TO BE ESPECIALLY SENSATIVE TO SUNLIGHT. 3. WEAR PROTECTIVE EYEWEAR. FAILURE TO WEAR GOGGLES MAY RESULT IN SEVERE BURNS OR INJURY TO THE EYES. 4. I UNDERSTAND THAT IT IS RECOMMENDED THAT I USE AN INDOOR TANNING LOTION FOR MORE POSITIVE RESULTS. 5. MINOR CONSENT. 1 VERIFY WITH MY SIGNATURE THAT I AM 18 YEARS OF AGE OR OLDER AS REQUIRED BY LAW. IF 17 OR UNDER, A PARENTAL OR GUARDIAN SIGNATURE MUST ACCOMPANY THIS FORM. ANY INDIVIDUAL UNDER THE AGE OF 14 MUST RAVE A PARENT OR GUARDIAN PRESENT WHILE TANNING. - 6. I UNDERSTAND AND HAVE BEEN MADE AWARE UNDER STA'L'E LAW, I AM ONLY PERMITTED TO TAN ONCE IN A 24 HR PERIOD. I HAVE BEEN GIVEN INSTRUCTIONS FOR THE PROPER USE OF THE EQUIPMENT AND I WILL USE IT AT MY OWN RISK. I HEREBY RELEASE THE OWNERS, OPERATORS, AND MANUFACTURERS FROM ANY DAMAGES THAT I MIGHT INCUR DUE TO THE USE OF THESE TANNING UNITS AND FACILITIES. MEMBER SIGNATURE [1111100 PARENTAL CONSENT DATE 11 TAN BED I TIME I PACKAGE I AMOUNT PAID I STAFF INITIALS 11 SOLAR ECLIPSE OPERATING PROCEDURES 1. CHECK IN TANNING GUEST 2. REVIEW THEIR INFORMATION, CHECKING THEIR AGE, LAST VISIT AND TANNING TIME 3. CHECK THEIR TANNING PACKAGE 4. DISCUSS WHICH BED THEY WOULD LIKE TO USE TODAY 5. RECOMMEND A TAN TIME TO THE GUEST 6. ESCOURT THE TANNING GUEST TO THEIR ROOM AND ENSURE THAT THE CUSTOMER KNOWS HOW TO OPERATE EVERYTHING IN THE ROOM. 7. COMPUTER AUTOMATICALLY WILL SET THE TIMER FOR THE DISSCUSSED TIME.