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Home My WebLink AboutHDBA-24-038 Duran tt�� THE COMMONWEALTH OF MASSACHUSETTS . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-038 FEE: $55.00/Technician This is to Certify that Dennis Duran 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. Gardi er ( Director alth • /11PPIN TOWN OF YARMOUTH Board °f 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 ub�D `JUN 2 0 2024 • Type of Application ❑New 71 Renewal Application Fee(s): $160/Facility $55/Tecliiii to $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility Tattoo Technician ❑ Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION splt-t eowc 028 Business Name&Ad ss . « O►A--1 1\M 4- ity State 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. Estabilment Owner's/Technicians Name: Oerin ) s OuiroW First Last Middle Initial Ie �9 /44 D of Bi Gender Tax ID#(establishment only) � qse s i-tth SY- 71- Z Legal Mailing Address h;) adjAo1ii p4- / q /L/( ity state zip 2-697. - it q-q 7-90 Phone Number Email Address 1 Created 1/24t2 PRIOR LICENSURE JUIN ? 0 2024 Has the owner or operator of the proposed establishment ever held a body art ,)Yes technician license or permit? - _MI DEPT. ❑No If ye please list the information below. Attach additional pages if necessary. State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) / PhiiaCUP1/1// c / 01DS&o 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 �� OeCD ❑ Medical Waste Removal Contract ,JU�I 0 2024 ❑ Bloodbome Pathogen Training HEALTH DEpy ❑ 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. • e.r)( S pUr0l Full Name of Applicant 1' lla /Zy Ignatu Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: .MR 3 yv • ProCPR CONTINUING EDUCATION'EQUNAENT TO 4D CLASSROOM HOURS Adult CPR/AED&First Aid l jai CEROUICATF NDMBER ;:eF t 6', Dennis Duran ti r� `A.';of 9202 RENEW BY a6(i u0TRUC.�-. 24 May 2023 24 May 2025 7WV _• ROY W.SHAW 4100 M6 CARD CERTIFIES THAT THE INUM DUAL HAS SUCCESSFUL°COMPLETED ME NATPNAL COGNITIVE EVALUATPN M ACCOROINt,WIM PROTRAIMNGS CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATION&CARDEUNFS www.PraUaIIIOOS[Om suPoortlry prolrainings.<Om L J ProBloodborne COWPDX.EDUCATION.EQ IVALENTTO34CIASSRDOR ROM Bloodborne Pathogens for Body and Tattoo Ei CERTIFICATE NUMBER Artists �• rr^ � p Dennis Duran �f• j 'i.4 Q�= \'aV DATE ISSUED RENEW RY MI a l�a1 INSTRUCTOR r1 02 May 2024 D2 May 2025 ROY W.SHAW 0100 1{`'`1�` •/// 0 (024 TH6 CARD CERTIFIESerAT TNEINgWOWINASS CESSPULLTCOMPLETED THE 3 V\• F.._ t- FDIIGTbNMOSHABt000BORNFPATNOOEMSTANOANO29CFR14101030 MID ROOT ART SAFETY www.protramings.corn sUVUGHtrvprotrainings.cpm L J HEN-TM pEPT. /�� 'ra r�Aa lAac arm 4 n�NT a'f R a 1 G 'r 1�� ,tiAx yr,rn:rrrrnru YsrtraurrYrr rrRa., .M4.41 sA ia+sn+a.A. r A inn Tom �� z1'•'yj ►A City of Philadelphia - Department of Public Health Body Art Artist - Tattoo y` orei. ks:,to ce„iO that �Po. Dennis Duran ii l�'�w... r> ,h t' (k' has heel,issuedtln tl I tattoois tinH L t atop d Cond t fI. ..,., .e0 A may h. e�,� and Body Piercing r.t lbl�l t Ti-. n t t h property !h Ph d 1ph D nt f Pll c H61F6REut N1'\1 {,{�„ revoked upon finding that 11 cirnfi hold. has not camplied ninth the obligation. appli ahk regulation of 1t0c 6 66,02 of 4>�t the Philadelphia Health(ode. �) . d IT`,':: cI wn 1 oSIL Th p.Fh.�a dia''.o c.�) � F ii!i It Certificate No.1080860 '' 1ti �.�w- (,g,r 1- I.et Anne R rota d �,°Y ''"ram t Issued:December 7,2022 fx I.nvtronmcntal En- ng N "a .14 ?tB`.r, Expires:August 11,2025 - Ptrviron„.1Health SCl,tc, Y1 t-E51 - 41r EIS f 'J 41 ' J - .�7, .J ,0 0 ✓I ✓ ..i a vl Av ,'6 ' 7 � e '•$4:E �'3tl'�IF t.i V.%/.ry��`� �riUSle�/iVJ` i��i�U�y !s }�`C �t3y :- ' A� 8, s DRIVER'S LiCEMU 'ow fva" iti NGT FOR REAL ID PURPOSES 03/13 989 moos 00 DURAN DENNIS PIMEN?Et fy5'0LTN STAPI - l'HIf A[iEi PHiA.PA 11 tae` dtPaa.•• •` 03/1412027 04/0412025 ,, Ni 11tge sR,.. yy�g+ r 1 „. ‘1-....-.' 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