HomeMy WebLinkAbout785 John Fitch Blvd 'Say," SF'9t
_ Town of South Windsor - Health Department
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1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
0,tiott•<<�` Phone Number: (860) 337-6173 Fax: (860) 644-1930
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:
Address of Establishment: IV6lei7�
Phone&E-mail of Establishment: -
Name of Manager/Operator*: iz=-, AC-11 A N
Phone Number for 24-hour Emergency Contact: 'M l -0 eJ- L122—
Name of Legal Owner: _�, �DE, "iC`�I,�P l
Address for Legal Notices: W_\ �\C2I�Q -1r
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License Fee:$50.00 per location
Type of Services Provided: ❑ Barbering❑ Hairdressing ail Salon ❑Cosmetology❑Threading
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Water Supply: 53/P/ublic❑ Private (well) Sewage Supply: Q Public❑ Private (septic)
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Is food or beverage provided for the public on site?BYES ❑ NO r HOURS Of OPERATION
SUNDAY to
If YES, please describe: cA
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� T��[�I !��Q MONDAY g CU to
i •J CA TUESDAY to
Appli nt Signature Date WEDNESDAY to
THURSDAY to
FRIDAY to p
Please Print Name b
*Nail Technicians are not currently required to obtain a personal SATURDAY to
license in the State of Connecticut.
Make checks payable to:Town of South Windsor
Office Use Only: Date Paid: Check Number: Cash:
Other: Rev 7/5/18
STYLIST CERTIFICATION INFORMATION
Name License # Expiration Date
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