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Home My WebLink About23-048- Ellen Stanley THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #23-048 FEE: $55.00/Technician This is to Certify that Ellen Stanley at Spilt Milk Mooncusser Tattoo HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31, 2023 unless sooner revoked. May 25, 2023, BOARD OF HEALTH: Hillard Boskey, M.D., Chairman (date) Mary Crai , Vice Chairman Charles Holway, Clerk Eric Weston James G. Gar er �• Dire alth > �"' a e Board of T 1, W .l'� O YA .�. M OUT Health i 1146 ROUTE 28. SOUTH YARMOUTH. MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231, ext. 1241 Division = Fax (508) 760-3472 Type of Application ew E Renewal Application Fee(s): $160 I Facility $55 /Technician $55/Apprentice 164 Type(s) of Body Art: ❑ Tattoo Facility pattoo Technician E Apprentice E Piercing Facility Piercing Technician ESTABLISHMENT INFORMATION 5 i W nA;f ) — ft10 1 i- 1?c U� ab-s4e c- flfb c-(1u 2g Business Name &Address w . okMr\ 0 2 Ce 3 - City State Zip Type of ownership: ❑ Sole Proprietor E Corporation ❑ Partnership If establishment is owned by a corporation, partnership, or other combination of individuals, please attach the name, title, tax ID4, and home address of all owners. Establishment Owner's // Technicians Name: WLn J tail J.0 First Last Middle Initial 0C0 /V 43 M Date of Birth Gender Tax ID # (establishment only) 319 i r ;0-f- s+ p LegalI-- iv MailingAddress i—af'-'& wok Cc�r'/ 0 2 zg City tate Zip 420 - ( Coa Co 2q 0 j ui s-tcc,n, 1 0..). ) • CPhone Number Email AddressG�� 1 Created 1/24/2023 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ems technician Iicense or permit? ❑No If yes, please list the information Belo v. Attach additional ages i necessary. CO ` ae-) vc4' 6L0J, I - BFN - 006 -7QS/ f&J'JV-., State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Has the owner or operator of the proposed establishment ever held a body art Yes establishment license or permit? ❑No If yes,please list the information below. Attach additional pages if necessary. State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: Yes No EMPLOYEE INFORMATION Please list and specify all Body Art Technicians (tattoo, piercing, apprentice) Employee Name Type of Body Art Performed 2 Created 1/24/2023 Requirements for Body Art Establishment Permit Submit the following to complete your application: ❑ A copy of owner's valid identification card with picture (state-issued license, passport, or military-issued ID) ❑ Detailed floor and operation plans of proposed body art establishment (new applicants only) ❑ A copy of Blood Exposure Control Plan ❑ Proof of liability insurance/ Workman's Comp. Insurance ❑ Client application and consent fowls • First Aid and CPR certifications • Medical Waste Removal Contract ❑ Bloodborne Pathogen Training ❑ Aftercare information and instructions Applicant Statement of Consent I understand that this permit is valid only in the Town of Yarmouth and expires at the end of the calendar year in which it was issued. I also understand that any notice to be mailed to me by the Town of Yarmouth Board of Health will be mailed to the address indicated on this application. I have received a copy of the Yarmouth Board of Health Body Art Regulations. I have read and understand the obligations and requirements imposed upon a licensed Body Art Establishment Owner/Operator by those regulations. I also agree to comply with all of the regulation requirements specified in the Yarmouth Board of Health Body Art Regulations while practicing in the Town of Yarmouth. I further understand that it is my responsibility to ensure that individual Body Art Technicians working in this establishment have a current valid Yarmouth Board of Health Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work practices regulations as specified in the Yarmouth Board of Health Body Art Regulations. I hereby certify, under penalties and pains of perjury, that to the best of my knowledge the information provided on this application is complete and accurate and in no way misrepresented. ftrtfi Full Name of Applicant ❑ n ture Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 A r�:a,naeusts JOIapunOdHd03euolleN rt.— U ,fdnad:mhn,lsut £zOZo2,'ez Uidy:uo!latdwoD 1111 1:88803d#01 sauslaP!nt,(1,VHV Put'11o01033:OZOZ aulu;rra a�ue0,0)3e u,pa,83s4u,wpe as,nop-SJeaA 2 3o1.p!!e;n,.uo,lepuno j Hdp It'uot3e}y}o suoe}rpuna g sur,ai. ay}t3tpm 4auepaoa3e u4 uogeurwexa aul ouissed Aq l)a(gns aul us Alua!a jo,d etu!legsuowap Aq asino)pauoquaw anoge ay}ul pay41a3 mou Si luapn4g Pauoquaw anoge aql Aalue;s uall3 ttJ W^�,rtl+34rl t teas i1A=3 P-a.�curvjarq- (luelul/PI!1)I linPV} 03V/tld3-p4epuelS NI NOI13ldIN07lf1dSSDDfiS�O NO111NOOD32! 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