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HomeMy WebLinkAboutHDBA-24-036 Cooke d THE COMMONWEALTH OF MASSACHUSETTS *Id TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-036 FEE: $55.00/Technician This is to Certify that Dwight Cooke 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 Holwayy, Clerk Eric Weston Laurance Venezia, DVM James G. Gard' er i(, Directo ealth 0r ill) TOWN OF YARMOUTH Hthf eal 1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508)760-3472 .— Type of Application JUG 0 2024 0 New 79 Renewal Application Fee(s): $160/Facility $55/Technician S5rtifi n Type(s)of Body Art: 0 Tattoo Facility (d Tattoo Technician ❑ Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION 41 tit MA tau 628 Business Name&Ad ss City State Zip 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. Establisbment Owner's/Technicians Name: q h t- COoKE- M First J Last Middle Initial 14 3 3- 2_ Date f Bi Gender Tax ID#(establishment only) Z b k i r/0 00a 2'V -C Legal Mailing Ad FrWGh-►-oVVp1 NJ 6 126` - boa City State Zip 12 '1- 3- Cl() k - ? tl3 i �y.11/7�j'clu7`rihrr) �Z�t��X43s' Phone Number Erliai1 Mddress • Created 1/24I2+ dtiN 2 U 2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever h a Ep1" es technician license or permit? If yes,please list the information below. Attach additional pages if necessary. State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) NJ kac/1f7 r 1- - Z2 - &" 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 1/24/20 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 ❑ Medical Waste Removal Contract JUN ) 0 2024 ❑ Bloodborne Pathogen Training ElAftercare 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. Qfgh C00 )% Full Nafde of Applicant ign ure Dat It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20 ?a rw c V y. ���«m»�© �« a§ . y; \ § » ®»«w« r- -- -- --- INI . . : , . _ ., "1 g .4 r , 4 . ! „ . __. ..., w ., :F.' -4-1'.''' i';i15'!:,;;;;:11::::.:, , z m i n t O p', .,° ` i C' O w , 3 M \\� J a - P A'Q Q m CO 1. ; 9,2 7 8 il �! a p 3 , z O \_i, . � O vuti d : w O d _ �* io ...2 ` wy-oo V a c _ O v,^_, oa0 u ,, rro o . a ° c ��\.. 5 a u c t - N e C „T Cb w - Oo _ N Vrn V O m S r G �g R y _ g _ ' =, 6D 1 o ' LL n y o m o^ o a O-- 3 c < u.z'r c d O ° fl- ,1 -v m LL ` Z c g # Z II Q m -- i _ o b - L _ NEWJERSEY'::MVC ' ,T• •*IV I E.; E . NOt FOR "'. `1 i"PURPOSES 'p = C6485.18474 047 ,_;..D 04 0 1fi07t - �,L� t2.16. 04.03-2026 r u .. u Ln 29 KrAAIte OoL A LION ? 0 2024 b c M ` HEAL- KEPT HE . " it-1 44, 1 i Wt„ rIMMIMMIIMI Business License City of Easton Department of Finance 0 IN NI Pr 123 South 3rd Street,2nd Floor,Easton,PA 19.042 This is to Certify,that on December 29,2023 THIS BUSINESS IS APPROVED TO OPERATE IN THE CITY OF EASTON y BUSINESS LICENSE NO.Ell-22-BOR Business Name FlymgDutchMan Tattoo Parlor Business Operator Name Dwight Cooke Business Operator Address 635 northampton st _ To Conduct the Business of: Other Expiration Date. December 31.2024 �,--- PLEASE POST IN PUBLIC VIEW .,;,,,••,,,,