MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
105 CMR 675.000

INDOOR ICE SKATING RINK CERTIFICATION/RENEWAL APPLICATION

Pursuant to 105 C.M.R. 675.000 an indoor ice skating rink operator must file this certification application with the local board of health.  Please fill out the following information. Please note that this form must be complete. Failure to provide the appropriate information can result in a delay in certification. 

Please fill out the following information: 

Application Status
Mark one selection 

____ New Application     ____ Renewal 

Rink Information 

Name of Rink: _____________________________________________________ 
Street: ____________________________________________________________ 
City: _____________________________________________________________ 
State: MA 
Zip Code: __________________________ 
Telephone Number: _________________________________________________ 

Owner Information 

Name of Owner of Rink: _____________________________________ 
Street: ___________________________________________________________ 
City: ____________________________________________________________ 
State: _________ 
Zip Code: __________________________ 
Contact: __________________________________________________________ 
Telephone Number: _________________________________________________ 

Skip the following questions in this box if not applicable:
 
If Owner is a Partnership, list general or other partners and addresses: 
________________________________________________________________
________________________________________________________________
________________________________________________________________

If Owner is a Corporation, provide the following information: 
State & Date of Incorporation: ________________________________________ 
Address of Principal Office: __________________________________________ 
_________________________________________________________________
Name and Address of President: _______________________________________
_________________________________________________________________

Operator Information        									Page 2 

If the person or entity responsible for the maintenance and operations of the rink is different 
from the owner, please provide the following information.  If not, skip to contact person 
information. 

Name of Operator of Rink: __________________________________________ 
Street: ___________________________________________________________ 
City: ____________________________________________________________ 
State: _________ 
Zip Code: __________________________ 
Contact: __________________________________________________________ 
Telephone Number: _________________________________________________ 

Skip the following questions in this box if not applicable: 
If Operator is a Partnership, list general or other partners and addresses: 
________________________________________________________________
________________________________________________________________
________________________________________________________________
If Operator is a Corporation, provide the following information: 
State & Date of Incorporation: ________________________________ 
Address of Principal Office: __________________________________________ 

Name and Address of President:_______________________________________ 
_________________________________________________________________

Name of Contact Person of 
Rink:_____________________________________________________________ 
Street:____________________________________________________________ 
City:_____________________________________________________________ 
State: _________ 
Zip Code:__________________________ 
Telephone Number:_________________________________________________ 

Dates of Operation of Rink 
Opening Date: _______________________________ 
Closing Date: ________________________________ 
Open Yearlong (circle one): 	Yes 	No 
Ice Resurfacer Information									Page 3

Brand of ice resurfacer: _____________________________ 
Fuel (Circle one): Gasoline 	Propane 	Natural Gas 
Other____________________________________________ 

Age of Resurfacer (in years):_________________________ 
Other____________________________________________ 
Catalytic Converter (Circle One): 	Yes 	No 
Date of Last Tune Up: _______________________________ 
Exhaust Discharge at (Circle one): 	Ice Level	 Above Ice 
Name of person/company who did last tune 
up: ______________________________________________ 

Secondary Ice Resurfacer Information (if used)
 
Brand of ice resurfacer: _____________________________ 
Fuel (Circle one): Gasoline Propane Natural Gas 
Other____________________________________________ 

Age of Resurfacer (in years):_________________________ 
Other____________________________________________ 
Catalytic Converter (Circle One): Yes  No 
Date of Last Tune Up: _______________________________ 
Exhaust Discharge at (Circle one): 	Ice Level 	Above Ice 
Name of person/company who did last tune 
up: ______________________________________________ 

Edger 
Brand of edger:_____________________________ 
Fuel (Circle one): Gasoline Propane Natural Gas 
Other____________________________________________ 

Age of edger (in years):_________________________ 
Other____________________________________________ 
Catalytic Convert (Circle One): Yes 	No 
Date of Last Tune Up:_______________________________ 
Exhaust Discharge at (Circle one): Ice Level Above Ice 
Name of person/company who did tune 
up:______________________________________________ 

Air Monitoring Equipment									Page 4

Type of air monitoring equipment for carbon 
monoxide: _____________________________________ 
Date of Last 
calibration: _____________________________________ 
Type of air monitoring equipment for nitrogen 
dioxide: ________________________________________ 
Date of Last 
calibration: _____________________________________ 

Ventilation 

Type of mechanical 
ventilation:______________________________________ 
Maximum air flow capacity (in feet per 
minute):________________________________________ 
Date of Last 
Maintenance:____________________________________ 

I hereby certify under the pain and penalties of perjury that I have personally examined and am
familiar with the information submitted in this form and that such information is to the best of
my knowledge and belief, true, accurate and complete. 

Date: __________________________________________ 

Signature: ______________________________________ 

Printed Name: ___________________________________ 

Title: __________________________________________ 

Form: ice1/1997