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HomeMy WebLinkAboutHDBA-24-032 Cotie \ „_/ THE COMMONWEALTH OF MASSACHUSETTS �� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-032 FEE: $55.00/Technician This is to Certify that Kaegan Cotie 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 Craig, Vice Chairman Charles Holzuay, Clerk Eric Weston Laurance Venezia, DVM James G. Gar finer (, Dir ealth /�" or r ift. 4.14i r TOWN OF YARMOUTH Board lhf t;r:.4,, .. 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 -R. -Division Fax(508)760-3472 ' ` U yVL7 JUN 2 0 2024 Type of Application HEALTH DEPT. p New Cl .&enewal Application Fee(s): $160 /Facility $55/Technician $55/Apprentice Type(s) of Body Art: ❑Tattoo Facility r— Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION 5 pi t-L M 90 4ti-/•c 0,23 Business Name& ess (Uri0IA-HI 1V4- O2�v72 t3' Zip Type of ownership: 0 Sole Proprietor 0 Corporation 0 Partnership - If establi hrnent 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: /e--g 19/1/ (? ;7--/ ,_ _-- p First Last Middle Initial A n_9 Date f Birt -I))r Gender Tax ID#(establishment only) W5 7 DZ Si, Legal Mailing Address TbAJ is k-/ (:),_al 'a 9-7 City / State Zip ?-)?0". 7-5/— /',?7 77,4-00 7/W(.' Cal'il Phone Number Etna Address 1 Created I/24I2023 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held * bod r 0 2024Yes technician license or permit? IfHEALTH DE No yes,please list the inforrmation below. Attach additional pages if necessary. a �� /I✓�/ — C- F O0Q2 S3 7S— state/Municipality Lic./Cert./Reg. # Status (Active/Expired ended) 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, ap rentice) 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 I Workman's Comp. Insurance 0 Client application and consent forms ❑ First Aid and CPR certifications ❑ Medical Waste Removal Contract ❑ Bloodbome 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. k19- 6/9-41 Full Name of Applicant Si natur Date‘///-96")'2r It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 -IL National Health & nr Safety Association Standard CPR/AED(adult,child,infant) STUDENT Kaegan Cotie Course administered by the National Health& Safety Association following the 2020 ECC/ILCOR IThis card certifies that the individual has successfully and American Heart Association guidelines. completed the requirements in accordance with the National Health&Safety Association curriculum. ID 467397-39498605AB For course details and CERTIFIED ON Mar 11, 2023 VALID 2 YEARS recertification,visit cpr.io 'mg B5ifd...w w'ii cfaeatkiea toCC4.rt3% ✓*nw Peen.CCMCt ins EeM.0,.0,Y'Jt.fKefU4 Tr m..actiee C F-'040-1732 Issued.CS l:,n lid OS Jt.fa. Uexnpt.on a Apocicahon FtM Et..ACLA Paynxn:Amount:$2S-00 Acc$.,Racerd O: 24TMIP-522993 _ - _ ^71 ,g ©BrsctyArtasts-ACLA t,uN .� �J r(tn{� Paynwnt Amoiwr525.00 t,J t'T AccNa Record0 .<•... ,, - HEALTH DEPT. st.W . Total: $50.00 P.vmmnt VsaCant ",..„...6G27 0227 ,1.._4', .l. R.I.f•MalCa NunAlr 001 SF5707 AuOavita4Koo Nunglr:04t8W MUPonw Coda. .!yqi Tvtwvsfc5 twf tCCL1JMItH* o r , :„_____ __. I®ENTIFICAT N / ,,, Das°3",sa-0 e 9e- 4:e .r,v 08/16/2027 OF COMPLETION fATtE SAECANPnMCI( IN RECOGNITION OF SUCCESSFUL COMPLETION IN: av; ecu„ ,- tWIIg t,,, l,t Bloodborne Pathogens All .t ; Infectious Disease Control Best Practices f Precautions ..ns 0610212022 a ,.-.... ,c e u ., ssr aRu •rya �. a.,:i -:� T1,6 CtRtif ICATE-!S PROUDLY 7rlrSf N161,,C;. Kaegan Cotie The above mentioned Student is now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the Terms&Conditions of National CPR Foundation-Valid for 1 year.Course administered-,n accordance with the 2020 ECCfiLCOR and AFIA guidelines. I0#:93CFFE7 Completion:June 4,2024 Instructor:Paul J.Scruton CNationalCPRFoundation" Signature:/1 i/ / ; fAc