HomeMy WebLinkAbout2018 Application - Body Graphics SON SF4`
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Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
r 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
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'ORA0 Phone Number: (860) 337-6173 Fax: (860) 644-1930
TATTOO 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.
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Name of Establishment: a y
Address of Establishment: 73 A J'An T U 13iv1)
Phone& E-mail of Establishment:
Name of Manager/Operator*: _r4e e<<. (. ir•de&k_
Phone Number for 24-hour Emergency Contact: F6,91" 5177' 7517
Name of Legal Owner: Oil Y C r«,_4iLS 76th�a2 ;2;1,i
Address for Legal Notices:
License Fee:$50.00 per location
Type of Services Provided: �N Tattoo❑ Body Piercing❑ Permanent/semi-permanent makeup ❑Other
Tattoo Technician License Information: *Please use the back_of this form if additional space is needed
NAME STATE LICENSE NUMBER , ECEIVED
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i U H WINDSOR
Water Supply: C] Public❑ Private (well) Sewage Supply:F]( Public❑ Private (s� ��ITIA DEPT.
Is food or beverage provided for the public on site? ❑ YES V] NO HOURS OF OPERATION
SUNDAY C �o�to`
If YES, please describe:
MONDAY to
V� �� TUESDAY in to g
A plicant Signature Date WEDNESDAY I' ` to
1 � THURSDAY to � r�
17 t� 5
Please Print Name FRIDAY )Nei to h1
SATURDAY �`m to pm
Office Use Only:
Date Paid: d V M Check Number: b2«1�_ Cash: Other:
Rev 7/5/18