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Home My WebLink AboutHDBA-24-044 Woolverton THE COMMONWEALTH OF MASSACHUSETTS 42-441 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-044 FEE: $55.00/Technician This is to Certify that Brian Woolverton 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 rdiner (, . Di o Health ��' 'A of TOWN OF YARMOUTH Health f 77111 - 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division • Fax(508) 760-3472 ElgigKED JUN 2 0 2024 Tvve of Application ❑New Renewal Application Fee(s): $160/Facility $55/Technic t - !�:i re lice Type(s) of Body Art: 0 Tattoo Facility Tattoo Technician ❑ Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION SPi �-t ,; t� c� ? 0 9g 4u-7'c D23 Business Name&Ad ss � ryt tA—E-11 AA 4— p Z 3 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: grime WO' O Yfiteto r) 19- First Last Middle Initial I f �1 Da of firth r�I Gender Tax ID#(establishment only) �3y / ed � Legal ailing Address 4 tr P19- / y 930 City State Zip g 8 5-2K-i go . odethavkoa.4 d Phone Number Email Address effkiai/.&41-1 1 Created 1/24/202: UL'� JUN 202024 ULa�J PRIOR LICENSURE s. , Has the owner or operator of the proposed establishment art Jes technician license or permit? /❑No If yes, leas list the information below. Attach additional pages if necessary. State cipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) NJ tA-F7d�►�r1 State/Muni ipality 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 1/24/2023 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) El 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 LION 2 0 2024 ❑ 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. 0j rl a,r) /1/ol1/erfioil Full Name of Applicant ;44460:zi &fill/Z ure Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 lw1 t ila ' -: HUNTERDON COUNTY DIVISION OF PUBLIC HEALTH SERVICES l-in' lrolt SANITARY INSPECTION REPORT Oel l ,: 1,ti( 1 ! I ,i /74 e r `.fr SATISFA oeo CTORY f i,,, - arN(S DATASHEE rs ARE AVAILABA E UPON REQUEST r�,r.) ,,,,,MISES AND Al THE DEPARTMENT OF HEALTH F'�.`7 cYPYI HUNTERDON COUNTY I ,.) DEPARTMENT OF PUBLIC SAFETY '4'1, DIVISION OF PUBLIC HEALTH SERVICES I,. So e 2,E, t.u' C�,tt/. np B ly ni _y,,,y COO Boy 94:10 'PPy11, .Alert vgkm New Jenny 0 08 2 2-29 00 .'L) 15081 788-1351 t(fe;,. AME Of NSPECT NGOFFCCtAL Pura) tr4AV _ NCcPMANETN'f-) TURE or CTFFICIAL P lwtt /10 {�• 7 7 t ^) 0-A;) sots ,.f ins sue saMuro Caro- v ,n t....Wm oro row..r. (-PA, (-4A .. pV0.4 VT N It*,.4.3 wm S{.-",leCt.M..o,e,ouw Oa�a tau\'! .lit �� a V'J 141 r — � d DRIVER'S LICENSE P j'e#i Ivafr'a y ":A, r, t-A NOT FOR REAL ID PURPOSES EL,7;Lr,GWI5D ,,,ehN 30 954 704 ,„,.,F. 00 (,t,) 1 ERT1t0�S'TON JUN 2 0 ?f124 BR AN ALEXANDER IJ#s:NEED Lid KUNTNERSVtLLF PA 18930 HEALTH DEPT. 12/0212027 2/14/2023 M r1rti HAi' ,Cy„ NONE �� 4iFS F 1t,4 DO ')_ f is HEARTSAVER 4 Heartsaver® Ameri<an . First Aid CPR AED '' Association CERTIFICATE OF COMPLETION Brian Woolverton BLOOD BORNE PATHOGENS TRAINING has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Presented TO Optional modules completed: /t //%��////� 1►(///��y//� r/■11/Ay// Issue Date Renew By -smz3 maozs Training Center Name Instructor Name I Sacr Clare,nos,. po,n.Anson Training Center ID Instructor ID 1,20050]5,0 ^xvs-z elitt400.414 Training Center City,State eCa d Code 1/4JV ante 2.010285202 J /I j Training Center Phone OR Code 5 Number --, . : 73,=ee-3000 Donna Allison RN BLS.ACLS-1 Training Site Name `-.4