HomeMy WebLinkAbout23-076 Dylan Good THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #23-076 FEE: $55.00/Technician
This is to Certify that Dylan Good
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 ofthe 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.
August 2, 2023, BOARD OF HEALTH: Hillard Boskey, M.D., Chairman
(date) Mary Crai ,Vice Chairman Charles
Holway, Clerk
Eric Weston
Laurance Venezia
James G. • er �.
Director of Health ,J�
:4
1. , _ TOWN OF ® U Boar
He l hf
�' 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health
`` Telephone(508)398-2231,ext. 1241 Division
Fax(508) 760-3472
Type¢f Application
ew El Renewal Application Fee(s): $160 /Facility $55/Technician $55 I Apprentice
Type(s) of Body Art: ❑ Tattoo Facility ,attoo Technician ❑ Apprentice
❑ Piercing Facility ❑ Piercing Technician
ESTABLISHMENT INFORMATION
5 i Ik- Y AA 11'- YY i cus rr c (1 Ra O- ZS
Busness Name &Address
l/k) • U ,V C� O v NS
1 A- 0 2 Ce -3
City
I State Zip
Type of ownership: ❑ Sole Proprietor ❑ Corporation ❑ Partnership
If establishment is owned by a corporation, partnership, or othemetiVaDof individuals, please
attach the name, title, tax ID++,and home address of all owners.
jut_ 28 2023
Establishment Owner's /Technicians Name:
C HEALTH DEPT.
Firs �c 1��6
t Last Middle Initial
� Z5 at of Birt110
Gender Tax ID # (establishment only)
5gO11.Scd 419
Le g g al Ma Address
frOcLdvi?)VFHS1
0 -He I/4l ��
C State Zip
N b7
(0
e um er Email 33 Address
Ph6h
1
Created 1/24/202
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PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art
technician license or permit? Ei No
If y s,p ease 1i t the information bel w. Attach additional pages if necessary.
d-h✓a�re PO N -l3 V L-. , �� / v
State unicipality 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 '1 Yes
establishment license or permit? D 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
RECEIVED
JUL 2 8 2023
HEALTH DEPT
}
I i
2
Created 1/24/2(
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 1D)
❑ 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 RECIER
❑ Medical Waste Removal Contract IrCa
❑ Bloodborne Pathogen Training JUL 2 8 2023
❑ Aftercare information and instructions HEALTH nEpT
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.
!( 1af) Ci0j
Full I ame of A licant
Si ature Date
It is your responsibility to renew your permit at the end of each calendar year.
3
Created 1/24/20:
RECEIVED
JUl 2 2023
HEALTH DEFT.
more al .
2023 Body Art Ope'ation Approval
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_ `r';:.`" •' ;
... �. acbo��elca requfirr}fn� o ap!�r3'7•r�o9'the Ohio Revised bocle and is
=,.suspension for cause and is not transferable without the consent of the licensor.
his tiaene must be displayed in a conspicuous place at the location.
Shelia L.Hiddleson,RN,MS
0000000
IS APPROVAL SHALL EXPIRE.ON DECEMBER 31,2023