LVO YMCA Pool Permit Application 2-16-2017 4�
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEAI;rH
:- 120 WASHINGTON S'IREET,4-FLOOR
1KIM13ERLEY DRISCOLI. TEL.(978)741-1800
FAX(9 7 8)745-0343 „s
MAYOR lramdincLsalem.cotn
I ARRY RAMDIN,RS/RLHS,CHO,CP-FS ll
HF;ALTH AGENT
FEBl LL:) J
,LEM
JF HEALTH
2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL D �
NAME OF APPLICANT (/ D TEL ?�Q�!
MAILING ADDRESS eq r A
CERTIF D P OL OP AT , I
Name: U c ki.[ i N Cert#:___ 4EL#_,?�Y - l 9
DATES OF OPERATION(if not annual): 624/121az/"
DAYS &HOURS OF OPERATION:
TYPE OF POOL
Public
Sc 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
file all Ve tax returns and paid all state taxes required under the law.
1�1, 2i l& 1 /7D 2- p " 13
Signature Date SS#or Federal Identification Numb r
Revised 5/23111 poolappl Ldoc Check#Date /] 1