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Home My WebLink AboutHDBA-24-033 Moretz THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-033 FEE: $55.00/Technician This is to Certify that Noah Moretz 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 Holway, Clerk Eric Weston Laurance Venezia, DVM James G. rdiner Dti cc or of Health or r tirk TOWN OF YARMOUTH Board of Health 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS `�?-------Health Telephone(508)398-2231,ext. 1241 - = -'Divi ion , Fax(508)760-3472 JUN ? U. 1024 HEALTH DEPT. Type of Application io New a .tenewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility /d Tattoo Technician 0 Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION 5 PI (± ikiji ' 90 4c/(71C C'Z3 Business Name& ess V'ty an r ' t Sta 0Zip• Type of ownership: ❑ 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: A/d/9-# Mae6-7"- --- -c , First Last Middle Initial 02 /igOe'V g r Date Birth Gender Tax ID#(establishment only) /// tneY Zak/ / Legal Mailing Address VV�//. . N - 2 ��°� Ci / State Zip 91/17-- 1` . - -7-3 /2 ez.h... .e)re �Q. Z, C0/27 Phone Number Email Address 1 Created I/24/2023 • G=� uvuD PRIOR LICENSURE AN j 0 2.024 Has the owner or operator of the proposed establishm� tamer eld a body art 0 Yes technician license or permit? ;-; .ACTH DEt�i ❑No If yes lease lis the information below. Attach additional pages if necessary. _ /&1JX Cil)t /�c" . , G7967 1 g State/Municipality Lic./Cert./Reg. # Status (Active/Expired ded) 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, apprentice) 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/ Workman's Comp. Insurance ❑ Client application and consent forms ❑ First Aid and CPR certifications E;. 10 LED ❑ Medical Waste Removal Contract ❑ Bloodborne Pathogen Training JON ? a 2024 ❑ Aftercare information and instructions HEALTH DEPT. 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. 4764 /7&) Full Name of Applicant e 11 /Z- 2Y Signature D to It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 r�— DRIVER LICENSE 1,1 NO I-FOR FEDERAL IDENTIFICATION - - 000035197150 02124/2000 L__` =_ ' a 02/24/2029 MORE Z (� ) NOAH SCOTT 1J�,IiV 1 U ?Or/4 116 RIPLEY DR U - GREENVILLE,NC.. --`,-4 c HEALTH DEPT. NONE M 5'-10".. .. /)IcI A 0312412021 0029457263 — it- a.-....4 MIIIIIIIII_ 04092612184 _ 1 fD NumM North Carolina Department of Health and Human Services I I 1 Division of Public Health Environmental Health Section Tattoo Permit E Permission is hereby granted to Noah Moretz to engage in tattooing as defined in GS.1304-283 at Eye Heart Tattoo-Noah Moretz,430 S Dawson Si,RALEIGH NC 27601 rw..o1r.A,nTe _ WAKE permit valid until November 28.2024 c,,my Fsr✓mon lM.e This permit is not transferable to any other person or place of practice ByCk, . t� rzE ' i/¢ iE ,. Eo vmror�l HeJie Spcd.h;t L 1,rl ''��,,,,a�'.: November 28,2023 Din 7 Thacn+nmrnl ofHcvAll giW H cn Ac.. ,1 nu< uffuemlm, • 24 «ul ongq sr,rtl arc diutnlily nW.YAknI w Uc w4 -nt'-r�GO Ail _ ,. ,.({., ' ProBloodborne crnESvnRTw y16MEDUIVAEteerro ecassR00M Bloodborne Pathogens for Body and Tattoo CERTIFICATE NUMBER Artists a' � 16Q69093386420 ar Noah Moretz r A1., DAZE ISSUED RENEW BY El� '. ROY W.SHAW A100 12 May 2024 12 May 2025 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION IN OSHA BL00000RNE PATHOGENS STANDARD 29 CFR 19101030 ANO BODY ART SAFETY .uww.prolra:ningscOm suppo�i+prol a:nings cum L J a'\t ProCPR. CONTINUING EDUCATION'.EQUIVALENT TO d O CLASSROOM HOURS aaaa Adult CPR/AED a First Aid o n o 10ERTIFICATE NUMBER 68416506893037 1 Noah Moretz 15 May 2023 15 May 2025 1 ROY W.SHAW#100 !HIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS CURRICULUM AND THE 2020 AMERICAN HEART A55OCIATION-GUIDELINES s pport@protralnings.corn L