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New York State Department of Health Tn gFie srog anni acl ti P ram Bu of C ni E i oodP ti reau ommu ty nvronmental Health andF rotecon Fee Determi on Sc u nati hedle Instructions Print the requested information. Determine the correct fee. Make your check payable to the New York State Department of Health. Mail this completed form and your check along with a completed Application for a Permit to Operate (DOH-3915) to the appropriate Department of Health Office within 30 days of receipt of this form. A $20 fee will be charged for a returned check. FOR OFFICE USE ONLY Received by Amount $ Cashline # Section A - Facility 1a. Facility Name: b. Facility Address: (No and Street, City, State, Zip) c. County: 2. Name of Operator: 3. Type of Facility: Tanning Only Salon/Spa Fitness Other Section B - Basic Fee (Two-Year Registration Period) Indicate the number of tanning devices in the facility, then multiply the number of devices by $50. Number of tanning devices X $50 $ Add a $30 registration fee $ TOTAL FEE DUE $ Section C - Certification I hereby certify that the statements made on this form are accurate to the best of my knowledge. Signature of Operator: Date: DOH-4494 (11/10)