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Home My WebLink AboutHDBA-24-048 Henderson ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-048 FEE: $55.00/Technician This is to Certify that Baylen Henderson 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 g, Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, D V M James G. rdiner Di of Health 1` "1" . .i `: TOWN OF YARMOUTH Board f = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health -- Telephone(508)398-2231,ext. 1241 —.-___, Division Fax(508) 760-3472 ___ Lida % V 2024 Type of Application HEA-I-TH DEpr ❑New 7Y Renewal Application Fee(s): $160/Facility $55/Technician $55/Appren ce Type(s) of Body Art: ❑Tattoo Facility Tattoo Technician ❑ Apprentice ❑ Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION 5 0 tt RA; 0 , ' 9g a/(74C 02g • Business Name &Ad ess City li( Urn()AA---11 RA 4- 02 (p -4-,3 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: fa,v1-66 14e,r) do--LsOti First Last Middle Initial iiif qj'gq Dat of Bt Gender Tax ID# (establishment only) 4/ 77L3OA1 gg ANCI-1--F- p Legal Mailing Address M 4 RS 1-t A U Cr 28 7. 63^7 712/ City State Zip b/(f- 3,33 - 3 y,31 10 1P.n1- oreP a4- (0/41 Phone Number Emai 1 Created 1/24/2022 PRIOR LICENSURE Ha- the owner or operator of the proposed establishment e'er ek _bed art 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) AJCMaJs17a%( /OS 7 b /QD D 1 State/Municipality 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 I/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 JUG l% ❑ Bloodborne Pathogen Training H 2 U 2024 ❑ Aftercare information and instructions HEAL H 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. # ,7d&, ate Full N e of Applicant (4i0/2y ature Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 ! \ b57rolAxs North Carolina Department of Health and Human Se ices M American A2964412 e.aw Division of Public Health Em-irtmmenta'Health Section . ,,Cord certoms mat 0 t`; Tattoo Permit �� 0 Baylen Henderson 4 7,t ff wAn AmerCon HWllh Cale AcadMry'e CarrlcliWm to tM CWree ef $G�iten LQl/p ��rA' CPWAED:Adult,Child,infant Per+niscion is hereby granted to validate Now a Flat Aid(BLS) to engage in tattoo1\ ing as defined in GS.130A-183 AmerKM Neale Core a aaemy (� n (1B/09l20Y4 OBA92ti, at Fch '�p iv.p, Hale) p�rnnnGN < 11 rtSIG� ��Srdo #"{� )n'1Grslu.�1- 153 Wte Competed Valid until AIA11205 _ _ Ild } permit valid until-______- 026 t,F,t t f ittli l.Oral mt att/era:df t any«_ , ` swt 4,oT ,r� jr�yl 7 VS,nS .ops e' "M"" "°"° Instructor Signature a s �,s�� ""� /4.1* . . Holder's Signature .. cairn caw ot o medical emergency Call t-eo0-M-1Tl]er 0 prison er oonn cy - �_�.------'-J i«CPRAEo a NM ledtraining lMwngem Cat-ell-xn-nee a vise cpreeec ours.tern ''.)A er ri Amwitan Health cote AcIXMmy ...,.... ,-.,."a,..,..,..„ Bannerol Recommended every 1 yews Baylen Henderson nos successNM completed this oni ne course &vi BBP for Tattoo z-j 7 Artists Online JUN 2 0 00 4 �_ HEAL171 DEpT • DRIVER LICENSE u00031287155 04/14/1989 04/14/2030 r. HENDERSON BAYLEN MERE .,,; 434 TILSON BRANCH RD MARSHALL,NC 28753-7714 4014 C NONE NONE - F BRO v =1,- ' 5'-06" BRO 4 - 12/14/2022 0033837719 04/14/89