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HomeMy WebLinkAboutHDBA-24-062 Hennesy THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-062 FEE: $55.00/Technician This is to Certify that Kevin Hennesy 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. Ga finer Director Director o ealth /�� Or TOWN OF YARMOUTH Board of Health �� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)3 -p 98 2231,ext. 1241 Division Fax(508) 760-3472 • Tvae of Application 0 New 71 Renewal Application Fee(s): $160 /Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION P I (7t MA 1 • 9g 4(171C °Z89 Business Name&Ad ss . (4(amr� t- I1A 4- _jZ(v�-.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: /C /its I-7eN/rsz5 / First fa Last Middle Initial '7 /7/ /22 • Date o Birth Gender Tax ID#(establishment only) /-/V 1f)7211/ S'77 Legal Mailing Address DEN VM gac /Y City State Zip -?/6 Phone Number Email Address dei, [/ l C'-i i lf -a/2c/ 4 7M41/(- ean2 • Created 1/24/2023 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ❑ Yes technician license or permit? ❑No If es,please list the information below. Attach additional pages i necessary. � VE- ' ,:20 ,OFN—QOO y S State/Municipali Lic./Cert./Reg. # Status (Active/Expired/Suspended) 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 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 ❑ 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. Full Name of Applicant Ka/f',/0 . 5---/16/ Signature Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 - - - - n =�S 'TM:: •Y� , 1. r�::fit,M ProCPR� « 4BC� o .� �MN By ProTralninq '< sG NT 171 9'C'TC"€ .AP�+,x Tt=Rocs ,_,- Adult CPR/AED Et First Aid El3i1:11 0 168494733702555 Kevin Hennesy ;•I DATE ISSUED RENEW BY 1 INSTRUCTOR 02 May 2024 02 May 2025 •tire •-• ROY W.SHAW#100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATION®GUIDELINES www.pro Vainingscom support@protrainings.com L J . ,� DL Q License No: 2021-BFN.0007485 DRIVER LICENSE W w• Name: KEVIN HENNESSY : TR1Ca • DOB: 09/17/1987 2 1b Vft PAT IC 4 OERVE1r.C080219 ,x DOB !a As ea ErMelumenrs Z 4�Op1171pi►7 10J1�01• wrs. i, aA c o+* ItlannBw ee E p 12 Restocaonc o,.,,, ,,;t72a Expiration: 09/13/2024 Peevaws Tvw i VeafHe CN1Getllcatrons Q V :�? 28t1;88 A R lJJ e ol" n This badge must be clear) y displayed, S�,h � and a copy of your license must be carried at all times while you are ^�IT', © H'` ' providing services. •.ar -�P ro B to o d b o r n e CONTINUING EDUCATION:EQUIVALENT TO 30 CLASSROOM HOURS `�` 1 I N -ter.i'+-QC,, OGET sv*1 HOW Pr,,rUA ,IN:!.NC,i Nr slot Al.Gh` 01 I O. By ProTraini,n,as Bloodborne Pathogens for Body and Tattoo �,ti . PI, Artists �F . 168389893386423 • e.1— • Kevin Hennesy '4.' �•; DATE:SsUED RENEW BY n 1.1 I +O ▪ R,!OT P(t..rr,c 02 May 2024 02 May 2025 ▪ ROY W.SHAW #100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION IN OSHA BL000BORNE PATHOGENS STANDARD 29 CFR 1910.1030 AND ,3n code o-crier rfVrate c r,ibe:a;pm a n,.', car, a rr+=.;:.- BODY ART SAFETY www.protrainings.com support@protrainings.com L J