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Home My WebLink AboutHDBA-24-043 James THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-043 FEE: $55.00/Technician This is to Certify that Skylard James 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. Gardiner (, Director of Health /• ' or t. TOWN OF YARMOUTH Boardthof Hl 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 =v:157-0WLEDD JUN ? 0 2024 Type of Application 0 New ll Renewal Application Fee(s): $160/Facility $55/Technicciian $55tApprentice Type(s)of Body Art: ❑Tattoo Facility 7E1 Tattoo Technician ❑ Apprentice ❑ Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION S i (t 4u7,e 023 Business Name &A ss - 016(1 O1A--+1 AA -- O Z (P `3 City State Zip Type of ownership: ❑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: 5 Vary' JA,M el Firs Last Middle Initial /27. /74 D of irth Gender Tax ID#(establishment only) qL0 q NC/4 'K son s i- fl-p11 Legal Mailing Address Ver e ez-/ Ci State Zip P 7 2 - 1/20- 333 Amos-I- n@ a,1.C�'1 Phone Number Emddress � I 1 Created 1/24/2 JUN 2tt2024 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever he 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) CD ,� � 2023 -eaN -Do 239s� State unicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Has the owner or operator of the proposed establishment ever held a body art D 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 `UV � • ❑ Bloodborne Pathogen Training JUN 2 0 2024 ❑ Aftercare information and instructions HEALTH D E P T. 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. D:,Q1ard James Full Sfame of Applicant r O//�/2 4 \ 3s re Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: : ...... r .., _ ,.. , . ,,i „jam American Red Cross �/��1t (LL�(�(�(-.� ^�� fdii.,i,vA sr rwrc` OF COMPLETION Certificate of Completion IN RECOGNITION OF SUCCESSFUL COMPLETION IN: P CPR/AED/First-Aid Skylard James (Adult/Child/Infant/Choking) AED/Injury 6 Universal Precautions has successfully Completed requirements to Bloodborne Pathogens Training Date Completed:6/4/2024 Skylard James Validity Period 1 Years Tne above mentioned Student is now certified in the above mentioned:nurse by Conducted by:American Red Cross demonstrating proficiency In the subiert by passing the examination in accordarrce with the Terms&Conditions of National CPR Foundation-Valid for 2 years.Course administered in accordance with the 2020 ECCtb,COR and Al-IA guideline, dD#:EFF9DED Completion:June 30,2023 Q"T •ii Instructor:Paul J.Scatter. 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