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HomeMy WebLinkAboutHDBA-24-041 Holland ts / THE COMMONWEALTH OF MASSACHUSETTS .) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-041 FEE: $55.00/Technician This is to Certify that Paul Holland 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 cAet..0 James G. G. •liner , Director . " ealth ej op TOWN OF YARMOUTH o °f 1146 ROUTE 28, SOUTH YARMOUTH, MASSA HUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241L°__ _ Division Fax(508) 760-3472 JUN 1 U 2024 T�of 4pplication HEALTH D E PT 0 New li Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: ❑Tattoo Facility /`- Tattoo Technician ❑ Apprentice 0 Piercing Facility © Piercing Technician ESTABLISHMENT INFORMATION Spl (It NA; Q 98 4u7le 0,28' Business Name &Ad ss . Urn A AA 01 . 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. Establishment Owner's/Technicians Name: Pal Li H-o/ IiiJJd First Last Middle Initial ► 14 1( 3 1714 Date f Birth Gender Tax ID#(establishment only) Leg Mailing Address 1\,)e O1La,nS VII5 City State Zip 041,1/' (01 Phone Number P6010 Email Address 1 Created 1r24n+ JUN 2 U 2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ev ',d' 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) L & tOn 16u 1-15-g0 State/Mumcipality Lic./Ce ./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) CI 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 U 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. PtW ttvll a d Full Name of Applicant &fie/o Signatu Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20 LOUISIANA 1 DEPARTMENT OF HEALTH Food and Drug Unt i 628 N..4Th ST,Baton Rouga Louisiana 70802 Dr.Courtney PhhiiPs,P'.[. .John Bet Edwards P.O.Box 4489,Baton Rouge Louisiana 70821 SECRFTAft GOVERN0t4 Ph,No:225-342,7533 Fax No:225-742.7672 i . COMMERCIAL BODY ART Certification of Operator Registration 1 1 PAUL HOI.LAND This is to canny chat Art Law(R.S.40:2832tD`).anrt has suW Willie lly f rho,red Ins required training In first nIB.CPFP has duly registered with the Department of Health as required by Part)OCV711 W Title 51 Or trio Louisiana Administrativa Code{§301 and by the LII.:ls(el5 Commercial Body and bloodborne pathogens and disease transmission preven'I Cerloicate B 43580 THIS CERTIFICATE IS NON-TRANSFERABLE .1-1111411 z.W Katherine Btenco Otlasa January TB"2024 4i0 Program AdminiStF2tDr ISUUe DHte '.— a, 3 Louisiana meeood treux---- t �._ Or.Joseph Kanter,M D December 31,2024 �'�— State Officer Expiration Date ettla,'''v„,.. te`.l_t/, `.'�C C�B if t)e r.'"C S.Ia",.:1=. ?::s.. A93o..._ tsDb�D ler;0) , 1,mAR 040L D U K ?AU uwTED STATES a JUN 2 0 2024 TENNESSEE HEALTH fl DEPT. 07 AM 2032 UNITED STASES DEPARSSEENT M STATE P<USAHOLLAND«PAu L<K«««««««««««<c Ap64697701USA8303143M3206076796555642<671052 CliProBloodborni✓ Bloodborne Pathogens for Body and Tattoo ATE NUMBERArtists Ky. 168494977102556 Paul Holland BATE ISSUED RENE*CTMSTRUCTOR 02May 2024 -, - - • ROY W.SHAW*100 THIS CARD CERTIFIES THAT THE INOr0OILAL HAS SUCCESSEDLET COMPLETED THE EDUCATION IN OSHA BLOODBORNE PATHOGEN STANDARD E9 CFR 19101030 AND BOOT ART SAFETY www4Hotrain,ngstem wpponpPmwlMngE.eenl L J --1` } 1 • 801048.44 i4{SI• { 1S1 18,8u unmanla!Rt{10E AL- - /IV 1.qQ©15- jRVL ///oLLr47N,4 42-1-2o23 ,l g-moo 0 EC.! 0 ilialfh111ufir 1g U1dt8ID 0 Mimic ry A.:.coP AEo,,a....,R •••• ADULT FIRST AID I CPR AED „lt,..me..el A».e w...•