Business Information
Business Information
| Business Name |
Richmond Family Dental
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| Business Street Address (Including Unit or Suite, if applicable) |
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| Business Phone |
+18158621112
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| Business Fax |
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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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| Website Address |
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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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| Building's Landlord (if Different from Owner) |
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| Landlord Phone Number |
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| Property Management (If Applicable) |
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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, Wednesday, Thursday, Friday
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| Operating Hours |
Mon-Thursday 10am-6pm
Every other Friday 10am-3pm
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| Number of Shifts |
1
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| Number of Employees |
7
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| Nature of Business |
dental office
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Fueling Stations
| Does your business have fueling stations on site? |
No
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Hoses
Police Required Information
| Burglar Alarm |
No
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| Fire Alarm |
Yes
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| Hazardous Materials |
Yes
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Fire Alarm Information
| Please Describe Alarm Box Location |
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| Monitoring Agency |
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| Monitoring Agency Telephone Number |
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| Alarm Type |
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Hazardous Materials
| Provide Detail Information |
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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 |
Dr. Tehle
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| 1) Phone Number |
+18476516959
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| 2) Name |
Teresa Neel
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| 2) Phone Number |
+18153883299
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| 3) Name |
Beata Jarmosz
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| 3) Phone Number |
+18478903343
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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
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| Was this submitted After February 1? |
No
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Assign Certificate Number
Certification Number
