Application for Permit to Operate a Bathing Beach

Date of Application: ____________________________
City/Town: ___________________________________
Beach Name: __________________________________
Beach Operator Name: _____________________________________________________
Operator Address and Phone Number: ________________________________________
________________________________________________________________________

Address/Location of Beach: _________________________________________________
Water Body: ________________________________
Dates of Operation of Beach: From ____________________ to ____________________

Sampling Frequency (if not weekly, please explain): _____________________________
________________________________________________________________________
Are Field Data Forms completed in full for each sampling event? ___________________
Has Board of Health received timely notification of any exceedances/closures? ________

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For Board of Health Use Only
Does this beach meet the criteria set forth in 105 CMR 445.000? YES / NO (circle one) 
APPROVED / DENIED (circle one)   If Denied, Reason: _________________________
________________________________________________________________________
Board of Health Member/Agent: _____________________________________________

Permit granted on ______________ and expires on ______________, pending submittal of a renewal application at least 30 days prior to expiration. 

Permit Number: _____________________
Fee Collected: ______________________