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Home My WebLink AboutHDBA-24-045 Schmitt (sr" THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-045 FEE: $55.00/Technician This is to Certify that Dale Schmitt 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 �,ul��'7 James G. Ga finer (. Di ealth /��" oL o r Le"F TOWN OF YARMOUTI Hard f � 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508)760-3472 C - cy` JUN 2 0 2024 Tvne of Application HEgLT/7i ' Pr El New yf Renewal Application Fee(s): $160/Facility $55/Technician ntice Type(s) of Body Art: 0 Tattoo Facility 76 Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION SpIL-t RiciIK rcv&t20 . 90 amtc 023 Business Name &Address . «l O At--I� I�/ 4- U 2 (P q.; rty 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: Oa f i (S e,h m r t VV First Last Middle Initial 91 15- g9 M Date of Bi Gender Tax ID# (establishment only) J.a JatUL Ate Legal Mailing Address Ktnn9are Y 114 zi City State Zip P/ - /-7 - J3Q ,rtWen/ iove- et606 a,a. Co?) one Number Email Address 1 Created I/24/202 JUN PRIOR LICENSURE H Has the owner or operator of the proposed establishment ever he ' . ''? AlaT 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) N !� riC JJUZ --A-1a2C7 q7- ft State/M 'cipality 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) El 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 (MNa 2024 ❑ Bloodbome 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. Oo4 Full Name of Applicant ignature ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: . tt ProBlOOdbo one CONTINUING EDUCATION EQUIVALENT TO tiretaSRboM Bloodborne Pathogens for Body and Tattoo Artists a ,' ..•T'1:1 171340422225106 Dale Schmitt iwia • , i • Cr 677E Ir 202 2 may.RENEW 17 Apr 2024 17 Apr 025 • �'• • ROY W.SHAW 4100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION IN OSHA BLOODBORNE PATHOGENS STANDARD 29 CFR 1910 1030 AND .. BODY ART SAFETY WWW,protrainings.corn Support@prolrainings.corn L au P f O C P R CONTINUING EDUCATION'EQUIVALENT TO 2.0 CLASSROOM HOURS •. By P rir=nmd.gs Adult CPR/AED ••I ❑� CERTIFICATE NUM.M.- '.. 168389995886425 1,,`-...et+Ir Dale Schmitt 1..1+; • INSTRUCTOR ' D2'1fy513EO RENEW BYEi r•} i 12 May 2023 12 May 2025 r il• -• ROY W.SHAW 4100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS 5C.il coue e,emer<els, r to CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATIONS,GUIDELINES WWW,protrainirlgs.com supportioprolrainings.corn L _J tur,, rU ?'J?4 HEALTH DEpT I COUNTY r.Rll \ ox• ,- HE HEALTH L)EPAF 1 MENT Q5 , .SS The person or corporation hereinaRer named Is hereby TANS peen business of Body Art at the address stated below. comply W Rui anc �-v This permit a issued on the express condition that the Parmelee La s, the L; ay' NEW�) SfI"t•1TF I i comply with any and all applicable State.Local.and Municipal Laws, lS.F Al l.r and Regulations and maybe revoked or suspended by the Commissio `- ' �'_ D R i'J E R E f�.E N E of Erie for any failure on the part of the pemllttee fe meet such legs!r This perm ea - y This permit No.JJUZ-AR2G97 expires on 12/31/2024 unless sespen 9e5 r s !05`5113 E t E✓ SCHMtTT F MooemLor - DALE.\A' I Dale Schmitt N +1 KENMORE \t 142"' 2289 Delaware Avenue Buffalo NY 14216 dp, ; 4 e O NERU1 Y,`' b,. aet A4 02 ::.0 21_U t OPERATIO / We --gttrt$rlass owNEPIOPERATOR Tattoos 04/13120$8 Date Same I 7 NONE ,. riS r.4, H OPERATION(S) `e .NONE Tattoo Artist 08 20 2018 ram,; PERMIT CC PERMIT CONDIT IJN15I THIS PERM THIS PERMIT IS NOT TRANSFERABLE AND MUST BE POSTED IN A C