HomeMy WebLinkAbout23-066 Jesse Blatz „�/ THE COMMONWEALTH OF MASSACHUSETTS
J TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #23-066 FEE: $55.00/Technician
This is to Certify that Jesse Blatz
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.
July 21, 2023, BOARD OF HEALTH: Hillard Boskey, M.D., Chairman
(date) Mary Crai , Vice Chairman Charles
Holway, Clerk
Eric Weston
• James G. Gar er
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irect th
TOWN 4� F Jl_ A R" M a T
Y He a h f
11>a 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health
‘ftarkTelephone (508) 398-2231,ext. 1241 Division
Fax (508) 760-3472
Type of Application
KNew ❑ Renewal Application Fee(s): $160 /Facility $55/Technician $55 /Apprentice
Type(s) of Body Art: ❑ Tattoo Facility Tattoo Technician E Apprentice
❑ Piercing Facility ❑"Piercing Technician
ESTABLISHMENT INFORMATION
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Business Name & Address
(A) • ti akin°lA' MA- 0 2 Ce --3 ---
City State Zip
Type of ownership: ❑ Sole Proprietor ❑ Corporation ❑ Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the name, title, tax ID++, and home address of all owners.
Establishment Owner's /Technicians Name:
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First Last Middle Initial
ID ( 2 $�
ate of Birth Gen er Tax ID # (establishment only)
141 S . (Iva-0,r- s i
Legal Mailing Address
iefthr'ora. CO 8OO / g
City State Zip
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Phone Number Email Address
1
Created 1/24/2023
PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art 1>YRs
technician license or permit? ❑No
fyes, pl ase list the i ormati n below _Attach a d' ' l aces i necessary.
CO 0,01
State unicipality Lic./Cent./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 p 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
I �
2
Created I/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 forms
• 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.
6.5
Full Name of Applicant
Si nature ate
It is your responsibility to renew your permit at the end of each calendar year.
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Created 1/24/2023