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Home My WebLink AboutHDBA-24-064 Lapcheske THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-064 FEE: $55.00/Technician This is to Certify that Daniel Lapcheske 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. Gar .ner (, / Director alth / '' fi_A°r TOWN OF YARMOUTH Board Hof 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 • Type of Application 0 New 7g 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 S pl L-t K - 9g a/0.c 028 Business Name&Ad ess 1 rim 61A-I�I P 1 A 4- OZ (o -3 City p 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: First Last /1y Middle Initial //7//?q/ Date o Birth Gender Tax ID#(establishment only) /WO //a) /2//t/Lf A Legal Mailing Address /91&Alir 5--()(-; City State Zip 357- / i/ Phone Number Email Address 1 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 yes,pleas list the information below. Attach additional pages if necessary. • State/Municipality Lic./Cert./Reg. # Status (Active/Expire uspended) 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. a94 /t/.— C7-/ESie - Full Name of Applicant 94 terL e ignature at It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 IOWA DEPARTMENT OF PUBLIC HEALTH Bureau of Environmental Health&Contactor TTFRERY AUTHORTZFS AND PFRMITS Daniel Lapcheske The Iowa Department of Public Health hereby authorize this person to practice as a Tattoo Artist pursuant to the provisions of Iowa Code Section 135.37 and the rules promulgated thereunder. Permit Number: TAT-A-1309 Effective Date: January 01,2024 Expires: December 31.2024 • Ea{e Ken Sharp,MPA,RS,Dir' Division of CDPro(PR COv;NUMG E QVc,AT VA ON T TO BO CLASSROOM HOURS Adult CPR AE D E First Aid -_ El CERTIFICATE NUMBER 1692g077663,279 Daniel Lapcheske '�' Yr.w I 1 0 'NSTRUC TOR FI t.202 RE NEW BY Q 1 1 ROY W�� 23 Mg2623 23 Aug 202s THIS CARD CERTIFIES THAT THE BIDNIDUAL HASSUCCESFULLY COMPLETED THE NATIONALCOCNITNE EVALUATION IN ACCORDANCE PATH PROTWIMINGS CURRICULUM AND THE 2020A1ERICAN HEART ASSOCVSTIONH GUIOEUNES w99w,pTdninIgS can SuppOrtaprotralNrlg0TON L_ J . ProBloodborne :QNtiNUING FOLK 4TI0N EQUNA,NT TO i.B CLASSROOM HOIAS •-.. EV Prur.r .. Bloodborne Pathogens for Body and Tattoo y` CERTIFICATE NUMBER Artists "• .� 171S373YM3»» Daniel Lapcheske f i 30 MaY 2021 10 ROY SH MAY 2025 ROY W.iHAW 8100 THIS CARO EERY I'E,!'HAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION RI OSHA BLOOD00RNE PATHOGENS STANDARD 19 CFR 19101030 AND BOOT ART SAFETYom Fsr�m wppnn�p�otlanm.£s r. L_ J R4JYYt1. DRIVER LICENSE LAPCHESKE ' t"'. DANIEL ALEXANDER 1710 NW PINE RD ANKENY,IA 50023 t• 102881269 03l0212021 02/17/2027 a M 5'-10" BRO V,„: NONE • 02/17/1991 02/17/91 3S3:i."1B1Ls'�i t48 rA 1'022?f;