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HomeMy WebLinkAboutHDBA-24-049 Althen THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-049 FEE: $55.00/Technician This is to Certify that Scott Althen 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 Craig, Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, DVM James G ardiner � Director of Health Or drift- TOWN OF YARMOUTH Board thf 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 '" ... U 2024 Type of Application H ❑New Renewal Application Fee(s): $160/Facility $55/Technician $ Anti e Type(s) of Body Art: ❑Tattoo Facility 7fd Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S �► t-L RA;( 0 t/g a/7'c 628 Business Name &Ad ess ern 6 IA I M 4tate O1 (p �. Zip Type of ownership: 0 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: SeoTr- & First Last Middle Initial 36 m Da e of Biih Gender Tax ID # (establishment only) 72- /14(Y_ e1412 i2, Legal Mailing Address PI (Y o n /MJ, 6 A- 3132 -/-- (03s7- City State Zip q 10.J boy r;Sfera/ g corm Phone Number Email Address / 1 Created 1/24/202: PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body 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) State/M nicipality 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) ❑ 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 ??Z4 ❑ Bloodborne Pathogen Training HEAL T-H 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. CY(1,617t/97-//bW Full Name of A plicant tti d ature ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 ' EMERGENCY oao :T,; ::9i a _ fi 1'© ,,_. 03000094017230620 k. ",' . _ II , F, p, k ' ', ' EMERGENCY+1 , Certificate Of Completion � 1 phis Certifies bat ` y Certificate of Completion Fi Scott Althen r?.. 311is Certifies Chat has cum feted Adult CPR trainin that meet,the internaswnali led 2020 defines establishedb F a Scott Althen ��' P 5 Y asap guidelines > ILC()C,she International lotion Committee on RtaO.cfUOan,and the American Henri Association,and is /,. hereby certified by Emergency C rsa y h g completed the requisite cognitive steals ` has demonstrated competence of the appropriate cognitive skills associated ram. a tr„„"."1."" ens ••ore,,•71:I„w,`oaen••wM„e'MA. lea - 4;1.� with First Aid Training.You are hereby certified as u�a G�w.a,.,a�a,..�.nra. „ a.mua n .m,.o,cma�m ,m,,, • having completed First Aid Training. " F .a 6/16/2023 d-- 6I18f2025 ��.. 6/20/2025 . CERTIFICATION I)\TE: 0 s EXPIRATION GAFF ' CERTIFICATION DATE a"T` EXPIRATION DATE E {� n_ Ar.tp b? T '* „ ,,..,_. ;..5`..,a�n+: ...ten-.. t ,..• 4' rat 101900099017290612 ~tie .�' • • •' EMERGENCY IR ''i`+Q I ,.e t fie .{by '/ '/ / O. �r Certificate of Completion , _ = " i0 Ccltificc Cbat LJut� ..J _J Scott Althen U kt�24 ;,j has demonstrated competence of the appropriate cognitive skills associated ,-` H�T7 e with Blood Borne Pathogen Training. You are hereby certified as i f 7 DEpr having completed Blood Borne Pathogen Training. : 6/12/2024 6/12/2025 y } CERTIFICATION DATE et— EXPIRATION DARE T i & _ +� v f_py. �aa 1;^a %,tom« +,,* *1 rr;,. + ,'v+°.. I ';." YG171t "'"7 l -wax'.._ GseC/T�a+vt DRIVER'S LICENSE a G�aha�fa.e DL No.053869016 Don 07/3011973 B " a t ' - CLASS CM EXP 07/3012025 d I SCOTT GEORGE $ .& I 4t_7HE`1 €9 al f E. g E. >s a 72 t.ICCRADYDR RICHMOND HILL,GA 31324.6357 • rnd \p' Fp ERYAN, i O o "J , 1 Restr tions A End NO r + E w o ts� 06/26/2018 ` g v , V c 8 $' Sex M Eyes BRO ./>14,; _ g a ° .- - ► . 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