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HomeMy WebLinkAbout100 Bidwell Road - License - Fire Marsha (2) State of Connecticut • Department of Emergency Services&Public Protection Division of State Police Special Licensing&Firearms Unit DPS-23-C(Rev.7111) SrN�<, ` Official Use Only: raursr�vr State of Connecticut Department of Emergency Services and Public Protection BOXING FACILITY REGISTRATION Year: Name of Facility: Maximum Occupancy of Facility: Street Address City State Zip Code �� EGG >2 Sv . W���z Telephone Number of Facility: FEIN Number Email Address: fiQ - Zq0 - /`7`7 ©�D J O ©es � ,�f Name of Owner of the Facility: Contact Number(s): 12 417o-24 f460 Z,io Name of Manager of the acility: Contact Number(s): //-7 7 In order to be registered yearly, you MUST obtain and/or provide: (R.C.S.A. 29-196-42) 1. Certification from your local building official attesting to the suitability of your premises/venue for sparring or holding a boxing contest. ]Approve Denied Date:/-f=-/3 (441S Name of Local Building Official Siinattffe of Loca_ uilding Official Contact Number(s) 2. Certification from your local Fire Marshal attesting that the facility is in compliance with all fire codes. Approved Denie Date: -o/3 Name of Local Fire Marshal nature of Local Fire Marshal Contact Number(s) 3. Full description of the facility's sanitary facilities and emergency medical facilities. (`Attach additional pages if necessary) Sanitary Facilities: Restrooms: Locker Rooms: ff D Emergency Medical On-site: (Equipment&Personnel) INSTRUCTIONS: -Yearly registration of facility required. Registration period is from Jan. 1st to Dec. 31st of each calendar year -Each event held at registered facility requires fire marshal, notification, inspection and approval of floor plan and set up Yearly application must be COMPLETE and accompanied by a check or money order in the amount of$100.00 made payable to the"Treasurer,State of Connecticut" Registrant's Signature: Date: Return completed application, certifications and registration fee to: Department of Emergency Services and Public Protection, Division of State Police Special Licensing and Firearms Unit,ATTN: Boxing Regulation 1111 Country Club Road Middletown, CT 06457 An Affirmative Action/Equal Opportunity Employer