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Home My WebLink AboutHDBA-24-040 Mcelory Q(� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-040 FEE: $55.00/Technician This is to Certify that Rob Mcelory 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 er James G. G diner (, Director of ealth / • ` 0r. f TOWN OF YARMOUTH Board of Health 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241. Division Fax(508) 760-3472 uU4 / U2024 Type of Application HE ! T - a New r" Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility (d Tattoo Technician ❑ Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S PI Lt 7g 4u7`e 02g Business Name&Ad ss 60 . Cri1 O A+t1 I\11 O Z(o�.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. EstablWiment Owner's/Technicians Name: PO b Mccirmi1�- First Last Middle Initial Date r f/ � s3 Bi Gender Tax ID#(establishment only) kft ,rsor) r - Legal Mailing Address Ci State Zip P 508 -g 3 - -4- (.QW �am ram.m&,J roI of n @ Phone Number Email Address I pruil 1 Created 1/24/2 JUN 2 U 2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever=-`' ` ., P ies 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) 61/4 y r) 641- 2425- tOO9 State/Mn icipality 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 = =__ ❑ Bloodbome Pathogen Training ,'li i4 % U ,40 Z4 ❑ 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. • ROS mcEi,Roy Fu I Na I7 of App 'cant - / lel(a/zq S _ I ature Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20 Pi oi3toodborne 8loodborne Pa;'opens for Body and Tattoo , -v cnrr++un+Are.. Artists c � vr 1 lea c.Tnserwt Rob McElroy *I` 'tf .113 .r,..,,� r...., p. • „.....W.xx aalua. J)e.0.bX% !l t.,(1aR.k5Ti.r;rt tart.%)4104,rtt.14,400i.(,0.4.StW M tit).....W ata,X0/04.4 H.T10,4.NrW?VQ.1.O.MAW*WO >U+Mrsut, w..po mtvgAttymormwsom G �� YIN ? ud-,o74 f l;)roCP .,:.: . ..<e..Oa..Pb.fRNt V\S-P\` -\pEPT Adult CPR,A10 F1 rlr.t A Cr I Rob McElroy r_t7,.. i WI cna a 0 t - Or n*: • W)W SHAW al?) I OO1N1$53 O9 kt 244 I 00../NSI:rfY4 Ml Mlf1.0.0.".M N%AMI ,4atR1?10 he L J i City Of Taunton Board of Health BODY ART PRACTITIONER PERMIT POST CONSPICUOUSLY Permit: 8AP-2025-0009 $100.00 Online Permit Fee: c Payment; DATE ISSUED 04/01/24 In accordance with Regulations promulgated under authority of Chapter 94,Section 305 A and Chapter 11.Section 5 of the General Laws a Permit is hereby granted to' . Robert McElroy iSSAGHUSETTS DRIVER'S Body An Establishment same Pleasure In Pain Tattoo LICENSE Body Art EalaUehment Location 448 BROADWAY ? , Type of perms and any restnaons.Body Art Practitioner Permit 43 END 1 NBMBEA - t +1-2015 NONE S2DB 7998317 O 1 1812,2019 08-1 3 - Permit expiration date 03/31/25 4, ..y., wars* 2 REST I.SEX M .� D NONE ,e Board of Health `." ai/F--" APPROVED MCELROY t - Adam Or.Bryan Bagdasian,M.D ir, �'Y Vickstrom 'y "i ^R ROBERTA WSW. CHAIRMAN e 38 JEFFERSON ST )' / "' TAUNTON,MA 02780.2554 TAUNTON,MA Y 5 t10 O40ZT@75 Rev a}.132409 } '�'N^�wys..v,ra�.Mh`M swum rwrs.rsncw r.:.e:unn+V.+anaaea.0_in.S-(rStY.41.�.11n.iinm.t len9 hv.a814.m,1f