HomeMy WebLinkAbout201 Evergreen Way (4) Town of South Windsor — i Health M.!partment
1540 Sullivan Ave., South Windsor, C 1 06074— RPi iiiing Address
' 1630 Sullivan Avenue, South Windsor, CT 06074— Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Y�SOR Cn�
COSMETOLOGY LICENSE APPLICATION
Please review and provide the requested information for your establishment. Incomplete or
unpaid applications will delay the issuance of your license. Any license issued pursuant to this
application will be subject to applicable State and South Windsor Regulations, Licenses are not
transferrable.
Name of Establishment: CO c, _Ca a r,
Address of Establishment: (.01 E V e 0-cl re e r,\ wCl L.f s S+e a (4 S
Phone& E-mail of Establishment: 2;6O — L Lf"& — /q 1 S
Name of Manager/Operator*: Ko'K Ci'\ U0 nfA—�
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Phone Number for 24-hour Emergency Contact: 1�H 6 c-')-S4, b�5
Name of Legal Owner: Lr OCcCfmAz —T-r\c-
Address for Legal Notices: —1 0 B _—D—
N(!'k'J , �Jy 00kS�
License Fee:$50.00 per location
Type of Services Provided:❑ Barbering❑ Hairdressing❑ Nail Salon ❑ Cosmetology❑Threading
.Other (p(b& .tCC fCS'iny -fi>' CkSfD-�Werc)
Water Supply: [Public❑ Private (well) Sewage Supply: Public ❑ Private (septic)
Is food or beverage provided for the public on site?❑ YES ® NO HOURS OF OPERATION
I ( m�
If YES, please describe SUNDAY f to
MONDAY I to
TUESDAY �J to �
Applicant Signature C� Datel WEDNESDAY to o,
�j THURSDAY to c _
:-Q G SCC fVl c SV CcUL?,�l f J c(
Please Print Name FRIDAY /J to
*Nail Technicians are not currently required to obtain a personal SATURDAY p to
license in the State of Connecticut. RECENE
Make checks payable to: Town of South Windsor
OCT p � !
SOUTH VWINDSOR.
HEALTH DEPT.
Office Use Only:
Date Paid: 0 Z Check Number: �� Z Cash: Other:
Rev 7/5/18