Marion Board of Health
2 Spring Street
Marion, MA 02738
508 748 3530
2008 Marion Board of Health Application for license to
Operate an Inn, Lodge or Motel
Name of Establishment |
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Establishment Address |
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Establishment Mailing Address [if different from above] |
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Establishment Telephone Number |
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Name and Title of Applicant |
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Name of Owner [if different from applicant] |
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Applicant Telephone Number |
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24-hour Emergency Telephone |
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Number of rooms rented for service |
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Water Source [please circle] |
Town PrivateWell |
Sewage Disposal [please circle] |
Town Sewer SepticSystem |
Days and Hours of Operation |
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Dates of Operation if not Year Round |
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Pursuant to Section 49A, Chapter 62C, MGL, I certify under the penalties of perjury that to my best of knowledge and belief, have filed all State tax returns and paid State taxes required under law.
Social Security or Federal Identification Number |
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Signature of Applicant |
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Signature of Corporate Officer, if applicable |
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Date Signed |
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$100.00 payment is due with Application
This application is continued on the reverse.
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