hhs info

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Licensure and Regulatory Services
255 Rockville Pike, Ste 100
Rockville, Maryland 20850-2368
240-777-3986 Fax 240-777-3088
www.montgomerycountymd.gov/licensure

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TANNING FACILITY LICENSE APPLICATION
Application is hereby made for a license to operate a Tanning Facility in Montgomery County , Maryland

New  Renewal 
TODAY’S DATE____________________

Name of Facility:: _________________________________________________________ Phone #:________________

(include area code)     
Address of Facility:: ______________________________________________________________________________
Street Number and Street Name
_______________________________________________________________________________
City                                                                        State                                        Zip Code           

Owner or Corporation Name:: _______________________________________________  Phone #:________________

Owner or Corporation Address ::______________________________________________________________________
Street Number and Street Name


Hours and Days Open for Business: ___________________________________________________________

Equipment Manufacturers Name, Type, and Year:_________________________________________________

Applicant’s Signature:_____________________________________Title:______________________________   
Type Of Facility: Nursery                       Kindergarten             Elementary (state grades)____________

Secondary (state grades) _________  Post secondary (specify area of instruction)_____________

Accredited by State Department of Education?  Yes     No     

Maximum number of students at any one time:_________                          Number of students enrolled: _______

Do you intend to prepare/serve meals? Yes      No  (Bag and snacks are excluded from food service license)

Water supply: r Public        Private          Sewerage: Public        Private

Days and Hours of Operation: ______________________________________________________________

 

NEW FACILITIES OR CHANGE OF LOCATION FOR EXISTING FACILITIES:

  1. Anticipated date of opening or change of location: ____________________________________________

  2. Person to contact to arrange for an inspection:________________________________________________
                                                                                                  Name                              Daytime Phone Number
  3. Attach a copy of the Use and Occupancy permit for school use to this application.   To obtain, call the Office of  Use and Occupancy,  240-777-6240.

  4. Attach a copy of the Fire inspection approval call 240-777-2457 to schedule for a fire inspection with the Fire Prevention Bureau/Fire Marshal office.

Fee Information: Please refer to Tanning Fact Sheet

Submit completed application and application fee to Licensure and Regulatory Services, 401 Hungerford Drive, 1st
Floor, Rockville, Maryland 20850. Payment must be made by check or money order, payable to “Montgomery
County, Maryland”. We are unable to accept cash payments.
 

 

OFFICE USE ONLY

   
  Receipt Number:  ______________                  Date Issued:  _______________
  Amount Paid:  _________________   Date Expires:  ______________
  Check/Money Order Number:  ______________   Record Number:  ____________