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Home My WebLink AboutHDBA-24-065 Smiley THE COMMONWEALTH OF MASSACHUSETTS J TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-065 FEE: $55.00/Technician This is to Certify that Erik Smiley 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 Ja es G. G rdiner Dire ealth fl.ANI TOWN OF YARMOUTH Board of Health 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)3 - 1,ext. 1241 Division • 98 223 Fax(508)760-3472 • Tyne of ADplication 0 New 7ci Renewal Application Fee(s): $160 /Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility 7Ki Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION (t RA; 90 4w.c oZ8' Business Name&Ad ss Ci State Zip 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: ,9)7/ CX/9)6 First Last Middle Initial • Date o Birth Gender Tax ID#(establishment only) 3 L/ kh/lie/y /eo/t).� Legal Mailing Address W/9750/11/7)/t-- 0/9 ?S.-0 7,60 City State Zip OW/Ye' /kOCX-Orai( Caik_ Phone Number E l 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 ye le se li t the information be ow. Attach additional pa es if necessar . ') State/Municipality Lic./Ce4t./Reg. # ('C� d Status (Active/Expired/Suspen ed)" State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Has the owner or operator of the proposed establishment ever held a body art 0 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 ❑ Bloodbome 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. ,51 I/ EK Full Name of Applicant /a/'°?7 Signature D e It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 rr .... _._, .._ )e.iIf /cafe �1eW <�af OF COMPLETION OF COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION IN. IN RECOGNITION OF SUCCESSFUL COMPLETION IN: CPR/AED/First-Aid Bloodborne Pathogens (Adult/Child/Infant I Choking) Infectious Disease Control AED/Injury&Universal Precautions Best Practices/Precautions IIIIIIIIIMIIIIIIIIIIIIIIIIMIIII Erik Smiley Erik Smiley The above mentioned Student is now certified in the above mentioned course by The above mentioned Student is now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the demonstrating proficiency in the subject by passing the examination in accordance with the Terms 6 Conditions of National CPR Foundation•Valid for 2 years Course administered in Terms Si Conditions of National CPR Foundation-Valid for 1 yeal.Course administered to accordarn:e with the 2020 ECC(ltCOR and AdA)"guidelines. IC).4654283 accordance with the 2020 ECCALCOR and AdA s,guidelines Ir.) A566t 5 Completion:May 8,2024 Completion;May 8,2024 Instructor.Paul I.Scruton Instructor.Paul).Scruton �, /f cDUaSE MOM).6T _ n NattonalCPRFoundation' Signature:,1 i NatonalCPRFoundation" Signature ! ! 1,---- Ca � ��iausA DRIVER LICENSE FEDERAL LIMITS APPLY .-DL D6154526 CLASS C �� EXP 05/09/2027 END NONE LN SMILEY RN ERIK CRAIG 34 RANCHO RD WATSONVILLE,CA 95076 DOB 05(09/-1987 'tr RSTR NONE 05091987 Y C= paiert %e SEX,M HAIR BLN EYES BLU HOT 6'-01" WGT 170 lb ISS DD 0510312017583RB/DDFDI27 07/09/2022 I: . Ail. D. 0 BANG rn� .. : NTO N' ' TENTTES =.NTF DE TATOC' r'=':' . q4, r NOMBRE PATENTADO(A).GO OD LIFE TATS S.R.L last, Dueno Propedad 51171 - C.,Jula,3 r UbicacISnPLAYA CARMEN, 2 NTRO COMERCIAL N°Firma: 51171 N°Derecho:0 Distrito:CobanoZona:PLAYe £'' NOMBRE COMERCIAL:GOOD LIFE TATS ovzzo l z4 �/ / ` f a� . j -ri 1 ,5• eLICDA.ORLE DRIGAL.VILLEGAS IC'RONN r,cri RD"``y.:80 PM ENCARGAou DE PATENTES Di I "ON tSbTARIAY 'Fumes y seilos FirmasY S e fj p :i Fes` o debe ser culocado en un lugar visible y permanecer en et local