Business Information
Business Information
| Business Name |
Domenella Dental Care
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| Business Street Address (Including Unit or Suite, if applicable) |
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| Business Phone |
+18156782800
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| Email Address |
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| Would you like to sign up for the Village E-Blast for current events and information? |
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Business Owner Information
| Business Owner(s) Name |
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| Business Owner(s) Home Address |
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| Business Owner(s) Phone Number (Home or Cellphone) |
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Is This A New Business?
| Is This A New Business? |
No, my business was registered under the same name prior to May 1st of this year.
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Other Important Information
| Illinois Sales and Use Tax and/or Retailers Occupation Tax |
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| Operating Days |
Monday, Tuesday, Thursday, Friday, Saturday
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| Operating Hours |
Monday, 8am - 7pm
Tuesday, 8am - 7pm
Thursday 8am - 7pm
Friday 8am - 12n
Saturday 8am - 12n
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| Number of Shifts |
1
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| Number of Employees |
5
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| Nature of Business |
General Dentist
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Fueling Stations
| Does your business have fueling stations on site? |
No
|
Hoses
Police Required Information
| Burglar Alarm |
No
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| Fire Alarm |
No
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| Hazardous Materials |
No
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Emergency Contacts: Please provide 3 names/phone numbers of key holders who are available 24 hours in case of an emergency.
| 1) Name |
Kelly Domenella
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| 1) Phone Number |
+18155752477
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| 2) Name |
Ruth Nolan
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| 2) Phone Number |
+18478826659
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| 3) Name |
Marla Gackowski
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| 3) Phone Number |
+18153559078
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Initial Review
Late Fees
| Was this submitted after May 22? |
No
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Prorated Fees
| Was this submitted between August 1 - October 31? |
No
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| Was this submitted between November 1 - January 31? |
No
|
| Was this submitted After February 1? |
No
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Assign Certificate Number
Certification Number
