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Home My WebLink AboutHDBA-24-037 Destromp tr. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-037 FEE: $55.00/Technician This is to Certify that Tory Destromp 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 , Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, DVM James G. Gardi er Director of th 0r. TOWN OF YARMOUTH H thf tw.4,017 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 . G3LCMOVIDD JUN 2 0 2024 Type of Application -^T 0 New Renewal Application Fee(s): $160/Facility $55/Technician $55/A ntice Type(s)of Body Art: El Tattoo Facility /K Tattoo Technician D Apprentice ❑ Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION sp L-L 98 a/01c 028 Business Name&Ad ss . qr,- Ou-- 1111 - 0Z(t -q.3 City State 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. Estabment Owner's'Technicians Name: r0rI 06Stro�i L First Last Middle Initial 5 1 317- 5- Datt of Birth Gender Tax ID#(establishment only) cP f Oo c vjood rat dr Legal Mailing Adams Con na_po I / 3 MO 2yya1 City State Zip 11-3 - 5-3 - /�- Phone Number Email Ad ss 1 Created 1n4n1 PRIOR LICENSURE ,�JiN O : 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) emir' Orr 65-9610Z 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, 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 ❑ Bloodborne Pathogen Training JUN 2 0 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. 1-Orq OeStramr). Full Name, Applicant .0•71%. %/2y i'., �e Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20 . . i ty ,� a'u., na nc i -�,+ { r c t e- x t.. 1 ! O c$ r, 1 +mi$ a m z a n r !' a `m m -Zi n 2ALog a y i z ° _ - ppxgi $ ' SE.F2 a° m y , DOg Am 4a 1 c - v;ArT-il ' a I6]iVA m=(o §g11 ' . os x r)Z f oQomy Om °. °S 'g mzq" , D = gi e q g a' .9 8 r. r. moomn i V � m 9 ° _ �y 4. n �g ° f m m `g£R - °fT - �^ rN a ; ` _ _ao n Ha*1 M z f . m g o i', S m 3-Ai ram MARYLAND -- Driver's License DL C i MD-102711 i. 1: UESTROMP Gi 1U7LgD 961 DOGWOOD TREE DP, ANNAPOLISMD21409 JUN- 2 0 202 klghi ,,Yrchc L U C`t 05/18/1975 M 5%07" 130 05/18/2031 /''' M 03/20/202i HEALTH DEPT. C61 PRINT DOWNLOAD POF f V a Tory Destromp l 1 hat,aucce53fuuy tamp-Rated Ras aroma course Certificate of Completion Tory Destromp F Red Cross Red Cross BB P for Tattoo Artists has completed the requirements for Adult First Aid/CPR/AED Online Lli�� (Eligible for Skills Session within 90 1;y: Online days) '` '. _+ -rat conducted by ` is j l 1F�-L3 American Red Cross .-p.r January 31 2024 Date Completed:01/12/2023 al L1•Z•. _ ., # �„� Valid Period:2 Years 'a�ec` „ Certificate ID 013M472 Scan code or visit: https://www.redc ros s.org/take-a-cla s s/g rcode?certn um ber_0 13M472