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SOLAR ELIPSE TANNING 2011-TANNING - ESTABLISHMENTS (2)LoRNG /�vG�' Su v pc-iQ "ll., 4e, ' -v xe,.x? e4,,'' �p 2 xj nCommonweaith of Massachusetts 3 k -� ¢ :c2 r r-x d t # f ami `%' f rF _'°x'.-Ji 3 ¢.YA ` ' aCfty of Salem s 4 r �.:: a g a' Board of HealthVV =Klmbefley Dnscoll s � R� � �& 4 r SALEM MA 01970 . _ r ` D SUNTANNING ESTABLISHMENT PERMIT -z- DATE PRINTED s 01!03/20131 �,-41.ik 14 Lt dr" ',`e 2 C rz *>., c-k£ 3�.s �"'v, aE` '�' rC'v a LTYi&, '3� "��-"• ffi :h # F... 7x .` 4 '- ESTABLISHMENT NAME:' x '� Solar EcLpse Tanning " ` 1 £ S <,��? File Nu540 Lorin Avenue ,`. x"'� `sem � ' xe Salem' a a`y .J' MA01970 _. r tc n, *Ck A c 5 LOCATED AT X0540 CORING `AVENUE s�y,cs*. '3+ r SALEM, MA 01970,tx ,'r x wx��Perm�t Type' � '� �Perm�t No a� � Penut Issued /Notes �.., SUJVTANy BHP 20130348 Jill- Apr.1,2013 't Dec 31, 2013, $T40 00. ESTABLISHMENTg a - t ,g„O „ Fi,.a �, sx 3- � MY a.' s � :� s+. � 's --_ �� 5 � :� .s' €. a 'L � ,fi t r? - s ��-•: ?z �' �T�^r � a, �:-�=�sf- � -. v ys _ .Total Fees "5140 00 ,' re ''�3 <:,•y ! W" .�,. 4 af§ e moi' ii, ..+. " s 5 3 a r .:"'_ lea -'�Z �. 3rx a as fi-+'i f•E s y _ .9'. `` ea '*, ,_. ry. , a yOx?L �'"�'{'-..+r^'Ta '•S Y ffi z - a'' a -W 'i'zs S :-cr �:'• x _ c. . 4i rc a .x, w' 3sy Qi a'+ °�'z s`s- -" 5' PERMIT EXPIRES'; eceni er 31,=2013 * x a Board'of Health 777777-77777-7— N-A of s :r, ip� Vr' .'''- fx"� rT' a F-. i s-`a '� y$ k s 3s Page 1 XI s:, - KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD of HEaLTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAR (978) 745-0343 Iraindinnsalem.corn ) IiCI 8Itb P'— . p....... Pro—". LARRY Rr\M1n�IN, RS�RII-lti, (:1-10, CP -Il H Ii..V;l'1-I A(;u'xr TANNING FACILITY PERMIT APPLICATION Business Name: Cjpkp- &:-1;Pse— Phone# Bus. Address: SLAQ Lo('fos) Ay -C- Salem MA 01970 Owner(s) Name --RA -\D. 2er3Tr Phone # 8 - S - Owner's Address: '�� CA.( --r\ eALynn MA 6186`1 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 Wring 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. Signature of Applicartr Date For Board of Health use only _ Suntaaappll l.doc updated 523/11 Cheek date: /;V)f Check #: �'r_ SOLAR ECLIPSE TANNING SALON EQUIPMENT LIST 540 LORING AVENUE SALEM, MA 01970 (978)740-8867 BED # 1 SUN VITALE ROOM MANUFACTURER: SUN VITALE MODEL: SUN VITALE 5000 SERIAL NUMBER: 1047 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED # 2 JETPOWER MANUFACTURER: ULTRA SUN MODEL: JETPOWER 1700 SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED #3 MANUFACTURER: CREATIVE MARKETING MODEL: VHR 55 LAMP STAND UP SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: CREATIVE MARKETING INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/10/2001 SERVICE AGENT: DEREK HENTCHEL BED #4 SONNENBRAUNNE MANUFACTURER: SONNENBRAUNNE MODEL: SONNENBRAUNNE 30/0 SERIAL NUMBER: 560432 MODEL YEAR: 2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2005 SERVICE AGENT: FUTURE INDUSTRIES ULTRA SUN MAGNUM ROOM MANUFACTURER: ULTRA SUN MODEL: ULTRA SUN MAGNUM SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED # 6 BOMBAY ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT` DEREK HENTCHEL BED # 7 WINE CELLAR ROOM MANUFACTURER: AUVL SERIAL NUMBER: MODEL YEAR: ELIXIR 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT: DEREK HENTCHEL BED# 8 SOLART ROOM MANUFACTURER: A/C/N MODEL: SOLART 55/5 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 02/02 SERVICE AGENT: DEREK HENTCHEL BED#9 MYSTIC TAN BOOTH MANUFACTURER: MYSTIC TAN CO. MODEL: MYSTIC TAN BOOTH SERIAL NUMBER: 2002302 SUPPLIER: MYSTIC TAN CO. INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 08/02 SERVICE AGENT: RUSH WAGHORNE BED # 5 BED#10 LEG TANNER MANUFACTURER:ULTRASUN MODEL: LEGACY SERIAL NUMBER: 1423 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/03 SERVICE AGENT: FUTURE INDUSTRIES ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 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. 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 vour Preferred Method. ofHearine 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 eruptionor 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 Brun, 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. 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. I UNDERSTAND AND HAVE BEEN MADE AWARE UNDER STATE. LAW, I AM ONLY PERMITTED TO TAN ONCE IN A 24 FIR 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 DATE DO NOT WRITE BELOW THIS LINE. TO BE FILLED OUT BY THE TANNING TECHNICIAN TAN BED TIME PACKAGE AMOUNT PAID STAFF INITIALS Commonwealth of Missaciiuseits City.of Salem KIMI3ERL EY DRISCOLL MAYOR LARRY RAMDIN, RS/R1>1 IS, 010, CP -FS HFALTH A(H N'f CITY OF SALEM, MASSACHUSETTS BOARD OFHISALl'tr 120 WASI1INc'mN SrRI:ET, 4111 ftooit T1:1- (978) 741-1800 FAX (978) 745-0343 Ir,,tmdin(@saleni.com TANNING FACILITY PERMIT APPLICATION Business Name: Jo tar trC. esc k pr p; ea Phone # 111- 2140 - %R(; -i- Bus. Address: 5540 Owner(s) Name:_ aMGIAc Z�/bof Phone # 918 • Sri - 0OK-3- 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. ?/�/� 11 Signature of Applicant Date For Board of Health use only Suntaaapplt I.doe updated 523/11 Check date: /st o/ Check KrM. FRLEY DRISCOU, MAYOR 1.AIMY RWDIN, 16/RF.I IS, 0410, 01 -PS H kAl.; TI -I ACi I ANT CITY OF SALEM, MASSACHUSETTS BOARD OF HP.,Al, rl 1 120 WASHINGTON STREET, 4"' FL.00R TEL,. (978) 741-1800 FAZ (978) 745-0343 1ra1mdin(@salem.com MEMORANDUM Date: December7, 2011 To: Tanning Facility Establishment Owners From: Larry Ramdin, Health Agent RE: 2012 Tanning Facility Permit (application enclosed) DUEDECEMBERZB^ 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. SOMME BCU1'S6 TAINVING SMAIN EQ101PAREW ' LIST 340 LINING ATENHE SMALUt SNA 1119711 4971907JUD492967 BED # I SUN VITALE ROOM MANUFACTURER: SUN VITALE MODEL: SUN VITALE 5000 SERIAL NUMBER: 1047 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED #2 JETPOWER MANUFACTURER: ULTRA SUN MODEL: JETPOWER 1700 SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED #3 MANUFACTURER: CREATIVE MARKETING MODEL: VHR 55 LAMP STAND UP SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: CREATIVE MARKETING INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/10/2001 SERVICE AGENT: DEREK HENTCHEL BED #4 SONNENBRAUNNE MANUFACTURER: SONNENBRAUNNE MODEL: SONNENBRAUNNE 30/0 SERIAL NUMBER: 560432 MODEL YEAR: 2002 'SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES 'DATE OF INSTALLATION: 10/11/2005 SERVICE AGENT: FUTURE INDUSTRIES BED # 5 ULTRA SUN MAGNUM ROOM MANUFACTURER: ULTRA SUN MODEL: ULTRA SUN MAGNUM SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED #6 BOMBAY ROOM .MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT: DEREK HENTCHEL BED # 7 WINE CELLAR ROOM MANUFACTURER: AUVL SERIAL NUMBER: MODEL YEAR: ELIXIR 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT: DEREK HENTCHEL BED#8 SOLART ROOM MANUFACTURER: A/C/N MODEL: SOLART 55/5 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES, INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 02/02 . SERVICE AGENT: DEREK HENTCHEL BED#9 MYSTIC TAN BOOTH MANUFACTURER: MYSTIC TAN CO. MODEL: MYSTIC TAN BOOTH SERIAL NUMBER: 2002302 SUPPLIER: MYSTIC TAN CO. INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 08/02 SERVICE AGENT: RUSH WAGHORNE BED#10 LEG TANNER MANUFACTURER:ULTRASUN MODEL: LEGACY SERIAL NUMBER: 1423 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/03 SERVICE AGENT: FUTURE INDUSTRIES M ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 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 nearing From Us? TEXT EMAH. PHONE How long has it been since you've had a tan? Do you tan easily? Do you have a tendency to bum? Do you have any known allergies to sunlight? Do you wear contacts? Have you ever had a severe sanbum? 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 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. 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. I 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, ANDMANUFACTURERS 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 Have you ever been advised by a Doctor to stay out of the sun? Yes No If so, why? Yes No Are you taking any medications which are photosensitive? Yes No Do you have, or have you had during the past 3 months, any skin Yes No emption or communicable skin disease? Yes No Are You Pregnant? 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 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. 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. I 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, ANDMANUFACTURERS 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 r 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: BHF -2004-000277 Solar Eclipse Tanning 540 Loring Avenue Salem MA 01970 LOCATED AT: 0540 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SUNTAN BHP -2011-0315 Jan 1, 2011 Dec 31, 2011 $140.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $140.00 Board of Health Page 1 ` CITY OF SALEM, MASSACHUSETTS - BOARD OF HEAL"111 120 WASHING"1'ON STREET, 4TM FLOOR TFL. (978) 741-1800 I{IIviBF_,RLEY DRISCOIS FAX (978) 745-0343 MAYOR DGREENBAUMQSALEM. COM DAVID GREENBAUM, .. ACTING HEALTH AGENT TANNING FACILITY PERMIT APPLICATION Business Name: So�a� CSG\<n5r�4 ,rte; �a Phone # cl 1-j Bus. Address: �)`W Salem, MA. 01970 Owner(s) Name: 1aw,s. ,, Zf-lr . =�c. Phone # 9-73-5 J0-0c)�(T 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 a-. ' *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. Signature of Apph&rnt " "` Date i t i.: . For Board of Health use only .. Suntanappl revised 11/14/08 Check date; �7// e Check p: '314) ' �,yo 54ILAR ECLIPSE TANNING SAWN B/1111PAVElY ' LIST 340 IA/RING AITE\IIB SAL&Up ARA 1119711 I97:CI7�111-707:67 BED # 1 SUN VITALE ROOM MANUFACTURER: SUN VITALE MODEL: SUN VITALE 5000 SERIAL NUMBER: 1047 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED #2 JETPOWER MANUFACTURER: ULTRA SUN MODEL: JETPOWER 1700 SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED # 3 MANUFACTURER: CREATIVE MARKETING MODEL: VHR 55 LAMP STAND UP SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: CREATIVE MARKETING INSTALLER: CREATIVE MARKETING DATE OF INSTALLATION: 10/10/2001 SERVICE AGENT: DEREK HENTCHEL BED # 4 SONNENBRAUNNE MANUFACTURER: SONNENBRAUNNE MODEL: SONNENBRAUNNE 30/0 SERIAL NUMBER: 560432 MODEL YEAR: 2002 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2005 SERVICE AGENT: FUTURE INDUSTRIES BED # 5 ULTRA SUN MAGNUM ROOM MANUFACTURER: ULTRA SUN MODEL: ULTRA SUN MAGNUM SERIAL NUMBER: MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 10/11/2001 SERVICE AGENT: DEREK HENTCHEL BED # 6 BOMBAY ROOM MANUFACTURER: AUVL MODEL: ELIXIR 40/3 SERIAL NUMBER: MODEL YEAR: 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT: DEREK HENTCHEL BED # 7 WINE CELLAR ROOM MANUFACTURER: AUVL SERIAL NUMBER: MODEL YEAR: ELIXIR 2004 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 04/2004 SERVICE AGENT: DEREK HENTCHEL BED# 8 SOLART ROOM MANUFACTURER: A/C/N MODEL: SOLART 55/5 MODEL YEAR: 2001 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 02/02 SERVICE AGENT: DEREK HENTCHEL BED#9 MYSTIC TAN BOOTH MANUFACTURER: MYSTIC TAN CO. MODEL: MYSTIC TAN BOOTH SERIAL NUMBER: 2002302 SUPPLIER: MYSTIC TAN CO. INSTALLER: RUSH WAGHORNE DATE OF INSTALLATION: 08/02 SERVICE AGENT: RUSH WAGHORNE BED00 LEG TANNER MANUFACTURER:ULTRASUN MODEL: LEGACY SERIAL NUMBER: 1423 SUPPLIER: FUTURE INDUSTRIES INSTALLER: FUTURE INDUSTRIES DATE OF INSTALLATION: 08/03 SERVICE AGENT: FUTURE INDUSTRIES ALL EQUIPMENT PURCHASED FROM: FUTURE INDUSTRIES OF AMERICA 626 SURF AVE STRATFORD, CT 06489 800-346-3136 94ILME ""r= TAMENE6 "Ulm 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 emption or communicable skin disease? Have you ever had a severe sunburn? Yes No Are You Pregnant? • _ If so, how long ago? Always Bum, Never Tan Usuallv 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 ADFIERE 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. 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. 1 UNDERSTAND AND HAVE BEEN MADE AWARE UNDER STATE LAW, I AM ONLY PERMTITED TOTAN 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 1 MIGHT INCUR DUE TO THE USE OF THESE TANNING UNITS AND FACILITIES. MEMBER SIGNATURE PARENTAL CONSENT DATE W NU 1 W KI' I E tfELU W THIS LINE. TU HE FILLED OU'C BY ] HE CANNING 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.