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Home My WebLink AboutHDBA-24-035 Derpssett \��/ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-035 FEE: $55.00/Technician This is to Certify that Jerrad Derossett 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. Garth r (, Direct th /�'' t4Ar or /44Prik-- TOWN OF YARMOUTH Hof 1 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETI'S 02.664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508)760-3472 .JUN ? U 2024 HEALTH DEPT Type of Anniication ❑New 79 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility Tattoo Technician 0 Apprentice 0 Piercing Facility fl Piercing Technician ESTABLISHMENT INFORMATION Pht 11A;t t� 9B 4(A-7‘c ogg Business Name&Ad s . GOArnfl ik+il AA 4- 01 (40-4-,; City Stale Zip Type of ownership: 0 Sole Proprietor 0 Corporation ❑ 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 I Technicians Name: d ,rnaeJ O s S-e6 Lr First Last Middle Initial g/8y D of Birth Gender Tax ID#(establishment only) CrwCsOrl otr Legal Mailing Address wlIr� 6ireu) g-4 Li2/a/ ity State Zip Phone Number Email Address( a 7 1 Created trza JUiv ;; t121)?4 PRIOR LICENSURE HEALTH DEPT Has the owner or operator of the proposed establishment ever held a body art es technician 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) KV .6a rre 'i vy3z/ � 7- & State/M cipality 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 1/2412 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 C= ��L✓D E Medical Waste Removal Contract �'11N U 2024 ❑ Bloodborne Pathogen Training HEALTH DEPT. ❑ 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. drrad ocross-cm ame of Applicant q 2y Igna Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2C ProCPR :; I . Adult CPR/AED El ..43.CI CERTIFICATE NUMBER 168389995886499 Jerrad Derossett ..;'" OATS ISSUED RENEW BYE le 12 May 2023 12 May 2025EIM:••-• ROY W.SHAW#100 THIS CARO CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATION®GUIDELINES www.protralnings.com support(aoprotrainings corn L J 0 Pro B t o o d b o r n e CONTINUING EDUCATION.EQUIVALENT TO 10 CLASSROOM HOURS By.}•C Ir7 F.ifl:4S Bloodborne Pathogens for Body and Tattoo :WO CERTIFICATE NUMBER Artists + 168494977702556 114.1. Jerrad DeRossett :s I... ,,1 0� INSTRUCTOR GATE ISSUED RENEW BY 02 May 2024 02 May 2025 ' • ROY W.SHAW 8100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION IN OSHA BLOODBORNE PATHOGENSSTANDARD 29 CFR 19101030 AND BODY ART SAFETY www.protrainings corn support@prolrainings.corn L J KENTUCKY_ DRIVER'S LICENSE TN l? 0�`IL l7NOT FOR REAL ID PURPOSES )1:D00-412-102 q ,DEROSSETT 0 2�L4 JR ELYON DR {� ` 1 98ER0NILINADG D EN,KY42101 HEAL1r'I�1_� DEPT. w 10080511811984 JI€XP 0611812025 sass 0 '> INL NONE L'''.'"« IRE? NONE !? —- I,SEE to I rT€1 5'-07 OANTS MU 4a KS it V.'�Y i 5 00242104281014523101111 KEN 0412112021 BARREN RIVER DISTRICT HEALTH 34766 Cut Along Dotted Line CABINET FOR HEALTH AND FAMILY SERVICES COMMONWEALTH (tifOF KENTUCKY JERROD E. DEROSSETT is a TATTOO ARTIST REGISTRATION# 34766 EXPIRES: 12/31/2024 MATTHEW L HUNT BARREN RIVER DISTRICT HEALTH