C.M.R. 10, 144, ch. 227, app 144-227-A
LICENSE APPLICATION FOR CREMATORIUM
1. Owner/Operator of Facility:_________________________________________________
2. Name of Facility:_________________________________________________________
3. Facility Location: Street ______________________Town/City:____________________
4. Owner/Operator Mailing Address:____________________________________________ Town/City ______________________________State ______ ZIP Code ____________ Telephone: _______________________ E-mail: ________________________________
5. Cremation Retort Specifications: Enclose as Exhibit A manufacturer's specifications for the make and model of cremation retort(s) proposed.
Number of cremation retorts proposed: _______________________________
6. Water Supply: I Municipal System I Private Well
7. Wastewater Disposal: I Municipal Sewer I Private Septic System
8. Associated Cemetery: Is the proposed crematorium affiliated with a cemetery"
[] Yes [] No
Name of affiliated cemetery, if yes: ____________________________________________
Size of associated cemetery, in acres: _____________________
10. Storage of Human Remains: How will human remains be stored at the proposed facility prior to cremation" Use a separate sheet of paper if necessary. ________________________________________________________________________
________________________________________________________________________
11. Facility Plans: Submit as Exhibit B, a plan or plans showing the layout of rooms, storage areas, equipment, plumbing, and other features of the proposed facility, prepared by an engineer, architect, or other knowledgeable professional.
12. Right, Title, or Interest: Submit as Exhibit C, a copy of a deed, lease, contract of sale, or letter of interest establishing right, title, or interest to the property upon which the proposed facility is to be located.
Please complete this application form and deliver it to the Division of Environmental Health at the address below, along with Exhibits A, B, and C, and a $200.00 review fee in the form of a check or money order made payable to "Treasurer, State of Maine".
I, __________________________________________, state that the information submitted (print name)
is correct to the best of my knowledge and understand that any falsification is reason for the Department to deny the project.
SIGNATURE: ______________________________________ DATE:____________________
Mail to: Division of Environmental Health
Maine CDC
11 State House Station
Augusta, ME 04333-0011
C.M.R. 10, 144, ch. 227, app 144-227-A