The URL can be used to link to this page

Home My WebLink AboutHDBA-24-031 DeHoedt _/� THE COMMONWEALTH OF MASSACHUSETTS ) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-031 FEE: $55.00/Technician This is to Certify that Greg DeHoedt at Spilt Milk 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, 2024 unless sooner revoked. January 1, 2024, BOARD OF HEALTH: Hillard Boskey, M.D., Chairman (date) Mary Crai , Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, DVM a. James G. Ga finer , �� Direealth t I, TOWN OF YARMOUTH oarlhf He 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 9.2664 24451 HpA'th Telephone(508)398-2231,ext. 1241 �V -_� =JDivision Fax(508) 760-3472 JUN ? 0 2024 Type of Application HEALTH DEPT. /°°New CE -&enewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s) of Body Art: 0 Tattoo Facility Tattoo Technician 0 Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION pi L-t- " 90 4u7'c Business Name&A ess i . t f(1x 10 A'H 'A 4- Cl 2(v�-.3 ity State Zip Type of ownership: 0 Sole Proprietor 0 Corporation 0 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: First Last Middle Initial fd a /1.-6 /79 Da of Bird( Gender Tax ID#(establishment only) 3i/ 6I Z-019 G/9Nl Legal Mailing Address Nam. air City State Zip dos Phone Number Email Address 1 Created 1n4t2023 PRIOR LICENSURE �u 2024 Has the owner or operator of the proposed establishment ever he a KEPT❑ Y s technician license or permit? If yes please list the information below. Attach additional pages if necessary. /1/(7-- -#.16 351 01 (47-\:) State/Municipality Lk./ errt./Reg. # Status (Active/Expirea/ uspended) State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Has the owner or operator of the proposed establishment ever held a body art 0 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 JUN ? 0 2024 Submit the following to complete your application: CIA copy of owner's valid identification card with picture HEALTH KEPT. (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. 6g_ (90&,Y 1176)tD—r Full Name of licaht Signature ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 r _ OF COMPLETION7T DRIVER LICENSE IN RECOGNITION OF SUCCESSFUL COMPLETION IN: r,.e Sloodborna Patheyens "R.e. d`_. Infectious Disease Control T3'_ IOO'45613523 • 12/27/1976 Best Practices;Precautions 12/27/2025 DE HOE"' GREC.-WY NELSON Greg De Hoedt ,•nc SI ow,mentioned Student ty Mwr tenoned et the above mantwrnw course try t.,,.. a rotatory,n the saNeyt oy pessmg tore nedmmotton m accoro00ce WITH M. n tht lM of Not+onat CPR Foundation-Valid to;i riot.Course adminls,,,, a nrdonca wen toe 2020 ECCSICOR and AHA quehtroet. 4 495044E9 ._ .. • Completion May 29.2024 5 I t •... Instructor Pout1,Scrvton Syoatuec/1 V�,� 001858 4.1: '"NatfonalCPRFoundation" _`•el u + 1 ��.: UMC D AA 6 .-t:tce T.. ( townhall ai.. 0 Cr rae CP Receipt)P.. Q www.protr... JU T 2 0 2024 r- HEALTH DEPT. Adult CPR/AED a First Aid 0.41 , rf Greg De Hoedt 1:m2013 .a T 1025 ❑e;' ROT w SHAW et00 THIS CAAD MIMES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE L J 4035610017 North Carolina Department of Health and Human Services Division of Public Health Ens ronmental I Iealth Section Tattoo Permit Permission is hereby granted to GREG DEHOEDT to engage in tattooing as defined in GS. 130,4-283 at BAD FUN COMPANY,100 HOLDEN RD UNIT H,YOUNGSVILLE.NC 2?5w. Franklin permit valid until 05'30,2025 a sTATEa .a .n>•� p_ A Ihlilwnuwfi.•f liuM:.l tYpwc.4.n u:..k I aunruj..r..•.m.., ..hrm�M.•:, Jr ArW 4 .�J na