HomeMy WebLinkAbout2018-10-1 - 201 Evergreen Way - Cosmetology License Application tCww •t4 Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
' 1630 Sullivan Avenue, South Windsor, CT 06074— Office Address
` Phone Number: (860) 337-6173 Fax: (860) 644-1930
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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,"C—a a r,
Address of Establishment: (.01 E U erci re e r-\ WaH, S+e J (4 S
Phone& E-mail of Establishment:
Name of Man r/Operator*: _ Kc k K l(\ w�h
Phone Number for 24-hour Emergency Contact: L
Name of Legal Owner: Lr OCc Cfc Az —Tj,,\c-
Address for Legal Notices: +30 13k:n20LW Fk
N(?X, rk—I by Colo
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 I HOURS OF OPERATION
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If YES, please describe SUNDAY f to
MONDAY I� to
TUESDAY � J to �
Applicant Signature Date WEDNESDAY to o,
THURSDAY to c
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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. RECEIVEF
Make checks payable to: Town of South Windsor
OCT Q � !
SOUTH VWINDSOR.
HEALTH DEPT.
Office Use Only:
Date Paid: 0 Z Check Number: �� Z Cash: Other:
Rev 7/5/18