HomeMy WebLinkAboutHDBA-24-046 Willgues Cr f d THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-046 FEE: $55.00/Technician
This is to Certify that Richard Willgues
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 CraigQ, Vice Chairman Charles
Holway, Clerk
Eric Weston
Laurance Venezia, DVM
James G. G finer Direc Health
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it* TOWN OF YARMOUTH Health
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1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health
Telephone(508)398-2231,ext. 1241 r Division
Fax(508) 760-3472
JIM u r014
Type of Application HTH LiFpr
0 New Yfi Renewal Application Fee(s): $160 /Facility $55/Technician $55/App Tice
Type(s) of Body Art: ❑Tattoo Facility ( Tattoo Technician ❑ Apprentice
❑ Piercing Facility ❑ Piercing Technician
ESTABLISHMENT INFORMATION
S PI L- • C/g 46174C C'Zg
Business Name &Add ess
City t State Zip
Type of ownership: ❑ Sole Proprietor ❑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:
KiChtrd //V/ lig
First Last Middle Initial
/0(°25/E'5"L./atf Birt Gender Tax ID# establishment only)
y)
�33 3 g�,,re. ►'� l;�
Legal Mailing Address
D/oraa"c sprur?cs (1O g0 ll�
City State Zip
5 - 3w- D 00i •
Phone Number Email dress
1
Created 1/24/202_
PRIOR LICENSURE JUN 2 0 ?24
Has the owner or operator of the proposed establishmkLc erpteld a bpdy art 'es
technician license or permit? i ❑No
If yes, please list the information below. Attach additional pages if necessary.
State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
•
(i0
easo
S{ate/ unici ali Lic./Cert./Reg. # Status (Active/Expired/Suspended)
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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)
❑ 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'r4
❑ Aftercare information and instructions HEAD 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.
gichard
Full Name of Applic6ht��
f e �// , � 6//0/24/
Signatu / Date
It is your responsibility to renew your permit at the end of each calendar year.
3
Created 1/24/2023
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CERTIFICATE OF COMPLETION
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BODY ART COMPETENCY EXAM .F::1
THIS CERTIFIES THAT -I z
Richard Willgues o_ 2 t°z
w o "'
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has demonstrated proficiency in the Health&Safety in Tattoo Procedures in accordance J:(J _
with the El Paso County Chapter 6 Body Art Establishments Rule&Regulations -2 - --
W.
//\.,\DATE ISSUED'08/11/2023 EXPIRATION DATE'0n111/2025 Z
Public)(ealth 1.
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BODY ART PROCEDURES PERFORMED ANYWHERE OUTSIOE Of AN APPROVED,LICENSED RODE ART ESTABLISHMENT ARE
PROHIBITED.(SECTION 6.10i
I
JUN 2 0 2024
HEALTH DEPT