HomeMy WebLinkAbout23-079 Moises Exposito J THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #23-079 FEE: $55.00/Technician
This is to Certify that Moises Exposito
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.
August 17, 2023, BOARD OF HEALTH: Hillard Boskey, M.D., Chairman
(date) Mary Craig, Vice Chairman
Charles Holway, Clerk
Eric Weston
Laurance Venezia
• James . diner `.
: Director of Health /—"—J
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‘ifi..,. , -', TOWN OF YARMOUTHHeihf
- �' 1146 ROUTE 28, SOUTH YARMOUTH. MASSACHUSETTS 02664-24451 Health
Telephone (508 398-2231,ext. 1241 Division
Fax(508) 760-3472
Type of Application
7New 0 Renewal Application Fee(s): $160 /Facility $55 I Technician $55/Apprentice
Type(s) of Body Art: 0 Tattoo Facility Tattoo Technician 0 Apprentice
0 Piercing Facility 0 Piercing Technician
ESTABLISHMENT INFORMATION
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Business Name& Address
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City State Zip
Type of ownership: ❑ Sole Proprietor ❑ Corporation 0 Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the name, title, tax IDi,and home address of all owners.
Establishment Owner's /Technicians Name:
UiSS X OSi
First Last Middle Initial
01 1931A' 6/ M
Dateh Gender Tax ID # (establishment only)
/ 35 1) tr) /&
Legal Mailing Address
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yCit State Zip
Phone Number Email Address
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Created 1/24/202
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PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art ps
technician license or permit? ❑No
If, le fl the information below. Attach_ additional pages ifnecessary.� l aso. sA- go 1 z re
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 11 Yes
establishment license or permit? n 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
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2 Created I/24/21
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