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Home My WebLink AboutHDBA-24-034 Creasey , THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-034 FEE: $55.00/Technician This is to Certify that Matthew Creasey 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 g, Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, DVM 6-017 James G. G diner (. Director Health Z�" O* TOWN OF YARMOUTH Board of Health ku-,r,44"1- • 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Fax(508)760-3472 JU►N ? U 2024 Type of Application HEALTH DEPT io New Q .tenewal Application Fee(s): $160 /Facility $55/Technician $55 I Appren ce Type(s) of Body Art: 0 Tattoo Facility (` Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S�I L-t Ilti I K r 9g ahic oz8' Business Name&Address (UM iA Q (v-4-,3 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: iliftfink) UE095 CY • First Last Middle Initial /49/ Dat of Birt Gender Tax ID#(establishment only) Leg Mailing Address 032.E/--/IS7 City State Zip %,0 ere se -/c61ast /4 eak Phone Number Email Address 1 Created 1/24/2023 JUN 2 0 2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever hdii dra"t LI Yes technician license or permit? �"—-- 0 No If yes,please list the information elow, ,Attach additional pages if necessary. IZ7 G/2 Aitoa/ a- t/?& i?/a-- 3 yOc 74.7 r 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 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, 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/Workman's Comp. Insur. - ❑ Client application and consent forms E`` ❑ First Aid and CPR certifications SUN ? U 2024 ❑ Medical Waste Removal Contract HEALTH DEPT ❑ 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. T7?-''"I) 0C2f--79L-C )/ Full Name of pplicant j,I O.O7 ,/ Signature Dat It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 COMMONWEALTH of VIRGINIA Deuanment of Professional and Occupational Regulation E%PTAUS ON 'UHA Mavl.md Dove,Sane 400.RichH10nd,VA 23233 NUMBER 11-30-2025 "tele1hone'(SW,357)8500 1234001672 BOARD FOR BARBERS AND COSMETOLOGY APPRENTICE TATTOOER LICENSE DISPLAY IN PLAIN VIEW OF PUBLIC 0. Vi 1649 W BROAD STON CREASEY IV 11 Still Y 2 i,.,T X RICHMOND,VA 23220 .51,,,ir r alt Sr verlaf,1 at n1v,v dporr wryla;a.star ..,.ef-1 _-n JUN .2 U 2024 HEALTH DEPT. • ProCPR' CONTINUING Ee�,1�EQUIVAL0ESYaaa 014Lro neenIIQH.0.TO FORNthhih_.0'-I, COST H 0(AlORI, 0. By ProTTalnings Adult CPWAED 8 First Aid Ol ID CERTIFICATE NUMSF{ 168494733702945 Matthew Creasey ti 'rot :A'E ISSUED RENEW BY a 041' ROY W.SHAW#100 16 May 2023 16 May 2025 THIS CARD CERTIFIES THAT THE INDIVIDUAL IUSSUCCESSFULLT COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS CIIRRKULUM AND THE 2020 AMERICAN HEARTASSOCIATION0 GUIDELINES Wyrµ pro:Iamingzcom sup0ort'c protramiag.com L 1 ClOT' CATIONValidation Code:C3089886381528190 ( CARD ( Bloodborne Pathogens Joshua Mullins Authorized Instructor'Print Name) 63551 Matthew Creasey Registry No. has successfully completed the course requirements 02/17/2024 2/2025 for the Bloodborne Pathogens Program. class Completion Dole Exp.alwn Date 804-517-1352 125575 .rating Center Morn No. Training Center I.D. ASAFETR11 ThIs card certifies the holder has cOmpletad the course requirements as provided M a currently G !'�• BSAFETTO authorized ASHI Instn,clor.Cenac4,on does not guarantee future pct.-manse.or imply Iceman Heals a sale'' HEALTH■ or credentiali,g.Case content assets in satisfying the Inlom,atron and tramp requirements a resocus.ES �S�Inrdi,to INSTITUTE the U S.Department Al labor(OSHA29 CFR 1910 10 .Certification 301Period mry not exceed 12 � months hem cL ss completion. 'Vt_rgi:/ ry DRIVER'S LICENSE': Customer idestifter T69854098 name CREASEY .'.. MATTHEW,CAMERON L. Address 3801 TERJO LN CHESTER,VA 23831-1839 '1'• �` • Sex Class Date ol16irt6 09/02/1979 .• M D,M F Eyes Endorsements lox REIN' HAZ NONE 08/24/2017 r onto Dann, Height Restrictions Ex DD 079048512 SFT 11IN NONE 09/02/2025