Vinnin Square Rec Facility Pool Permit Application 5-17-2021 RECEIVED
MAY 2 4 2021
CITY OF SALEM
BOARD OF HEALTH
CITY OF SALEM, MASSACHUSETTS V
BOARD OF HEALTH Public$ tlth
120 WASHINGTON STREET,4W FLOOR Prerent.Promote.Protect.
TE1..(978)741-1800 FAX(978)745-0343
KIMBERLEY DRISCOLL healthna.salem.com
LARRY RAMDIN,RS/REHS,CHO,CP-FS
MAYOR HEALTH AGENT
APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL Caj 4 U c
NAME OF APPLICANT ��1�/��fN T�L#
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MAILING ADDRESS C� 14YKJ /? �U-�
EMAII.ADDRESS C/ C� / --
CERTIFIEU�POOL OPERAT r/ ,(/`
Name: ���� � Cert#:�' C1 j TEL# �1/' ` ` 4-tP Y53
DATES OF OPERATION(if not annual):
DAYS&HOURS OF OPERATION:
TYPE OF POOL
Public
Semi-Public
Special Purpose
Square Footage sf Volume (7JQ, gallons Bather Load S
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 Chop e�r 3C,Section 49a,I certify under the pains and penalties of perjury that I,to my best lmowledge and belief,
ha d all state t x retuins and paid all state taxes required under the law.
Signs a Date SS#or Federal Identification Number
Check# Date Amount
Revised 5/23/2017 poolapp I l.doc