The URL can be used to link to this page

Home My WebLink AboutHDBA-24-042 Schmoldt f_/ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-042 FEE: $55.00/Technician This is to Certify that Raymond Schmoldt 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. G diner (, Direc Health / ' JUN 2 U 2024 or TOWN EP MOUTH Board f Health 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 Type of Application ❑New 74 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: ❑Tattoo Facility Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION t-L 1/g 4botc 628 Business Name&Addttss et)m� P _ Uf Gown D A--+1 4- (}Z CP 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. Establishment Owner's/Technicians Name: gai v fri0i) SC/h n'? ) /Cl First Last Middle Initial 3233 / g� n/1 D of Birth Gender Tax ID#(establishment only) /a fv(5 hi 147 i 3h a_ ri o&-(eZ-Iy Legal Mailing Address iJJ1-LLI7ii Co Fo iz-7-- State Zip got/I -MO - 06Z-- Phone Number Email Address 1 Created 1/24/2 JUN 2 0 2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever tpply a rg''1°s 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) S to -cipality 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 anti 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 G .u ❑ Medical Waste Removal Contract JUN 2 U 2024 E Bloodborne Pathogen Training HEALTH DEPT. ❑ 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. Ramo11 Se o idt Full Name of Applicant (17( 0/9/1/ Signatirfe Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: ti. r'"r�ro CPR ' CONTINUING EDUCATION:EQUIVALENT TO 40 CLASSROOM HOURS a ,,a Adult CPR/AED&First Aid r 1-: El ERT,FiCATF N,tMRER OL ?r 16&135269303721 Raymon Schmoldt .:,..1 'DATE ISSUED RENEW BY 1444 L111 'ti';TRUC7Of=. 12 Apr 2023 12 Apr 2025 ROY W.SHAW 0100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS ,, CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATION'S?GUIDELINES www.protrainings corn supportoprotrann ngs corn L J ..JL National Health & "tr Safety Association Bloodbome Pathogens STt'O NT Raymon Schmoldt Administered by the National Health&Safety Association following OSHA Bloodbome Pathogens IThis card certifies that the Individual has successfully Standard 29 CFR 1910.1030. completed the requirements in accordance with the National Health&Safety Association curriculum. 641554-691592B5C8 For course details and CERTIFIED ON May 8, 2024 VALID 1 YEAR recertification.visit Cpr.io F I� CITY AND COUNTY OF DENVER rii\ DEPARTMENT OF EXCISE AND LICENSES 11111/11111111111111111110 11 �..{ 201 W.COLFAX AVEDEP0 02 *(((TII l'',11111U4��777,,,s ,��I D£NVER.COLORADO 307D2 /.*"' TELEPHONE:I720)SSS2740 0 -1- a/ INDIVIDUAL-PROFESSIONAL LICENSE DRIVE LICENSE POST IN CONSPICUOUS PLACE U A DOB 03l I'+1 186 BUSINESS FILE NO.:2022-RFNA000076 ,.DIA 17-128-6663 ISSUANCE DATE:06/t0/2024 EXPIRES ,:EXP 03/1412028 LICENSE TYPE:BODY ARTIST LICENSE 1TS102t202i 1 LICENSE HOLDER:RAYMON SCHMOLDT SCHMOLDT �' DATE OF BIRTH:0114/T986 RAYMON CHARLES ' g frOfi85 W APISHAPA PASS#06-624 BUSINESS INFORMATION urn.t t ON.Co 00127 ,� BFN 2020.BFN-0OOa977 CONDITIONS If any,these are conditions of licensure beyond the licensee's obllget On to follow all provisions of the Colorado Revised Statutes. (; - . iss.1111312022 Denver Reused Mance:HI Code.Promulgated Rules or any other city,state.or federal law Sex r Hgt5 0" Eye:BLU s Iacs R NONE ». - w Y c 0 . fir. ` IT IS THE LICENSEES RESPONSIBILITY TO RENEW PRIOR TO THE EXPIRATION DATE LISTED ON THIS LICENSE.IT SHALL BE _�f�1. +� UNLAWFUL TO OPERATE AFTER THE EXPIRATION DATE UNLESS D.vecl«.Excise and Licenses THE LICENSEE HAS FILED A COMPLETE RENEWAL APPLICATION AND MID ALL REQUISITE FEES.THE LICENSE WILL BE ADMINISTRATIVELY CLOSED AND ALL LICENSE PRIVILEGES WILL - "`-O Chief Financiy JM<e.BE FORFEITED IF IT IS NOT RENEWED WITHIN 90 DAYS OF THE EXPIRATION DATE.COMPLIANCE WITH ALL PROVISIONS OF THE DENVER REVISED MUNICIPAL CODE.INCLUDING COMPLIANCE WITH ARTICLE IV OF CHAPTER 28 IS A CONDITION OF THIS LICENSE.THIS LICENSE COVERS ONLY THOSE ACTMTIES LISTED