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Home My WebLink AboutHDBA-24-066 Brown THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-066 FEE: $55.00/Technician This is to Certify that Marshall Brown 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 Crate, Vice Chairman Charles Holway, Clerk Eric Weston Laurance Venezia, D VM James G. Gar ' er ,, Direct ealth Or kin% TOWN OF YARMOUTH Board Health f t"1"...41 ,. 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 74 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 L LMA t K 9 4/71C 028 Business Name &AddiSs 6v,tilrurrn ut-i-h 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 I Technicians Name: 0/9 /,9// 1/fO(c)/1/ 6/1 First Last Middle Initial i 3 q/ /I .� / Date; f Birt Gender Tax ID#(establishment only) '//` (: '? Legal Mailing Address C///d19 C lL 6C. V City State Zip • mars, ,2ro ,2@ eoiii Phone Number Email Address 1 Created 1/24/2022 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ❑ Yes technician license or permit? ONo If es, le se list the information below. Attach additional pages if necessary. , j�0 ,V3.�y5:3g State/Municipality 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. 7)2/9-/eS7Zbq C* 0066. ' Full Name of Applicant ,P"SI e ��-��- ,5 /o at' Signature Da It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 _ ` , .ease White•t.O0a'v OF Slate ,.. I1,L1NOIS °Row a ucauE +o f3650S478-3065 21\`III l�. ___ vm!:t ),�Yy/ .oa 03J03T'{4B3 t)glsm2o21 CITY OF CHICAGO _ 0303`2025 BROWN• B. ,'-�_ filly i .SARSCHEr#G LICENSE CERTIFICATE ' A05NCfhnH..6 PARK AVE ' •,` ,• C'rIIOAGO.L6UB24 C ef._ 1401E p = � NON-TRANSFERABLE _ I', a-54" ORG :I BY THE AUI000IIY OF THE CITY OF CHICAGO. _FOL'.:COOLS SPOON lb D LICENSE IS HEREBY GRANTED AD i BSobss GRN • 6: (",y„�.� oi o c I Sacrament Tattoo LLC Od/2211/Y0023i. Yw nuke BROWN BROTHERS TATTOO 0, 904 N. CALIFORNIA AVE., Floor 1 CBICAGO, IL 60622 I; j.I 2334538 4404 $•00•250.0i .ICENSE ND: Regulated Hvaineaa LicenaeCO'- I..,E. .. i uEEHSE Includes: Yahoo eatabllslwent: MANAGING WAGER:Maxwell 0.Broam ++ i • • PHSISTOY. THEREFOR • AND MAYBE SUSPENDED OR REVOKED FOR CAUSE AS PROVIDED BY LAW ULENSE SWU OBSERVE ANDOORPt l' 'I ry�WSORD..CES.RUES AND REDDATIO.OE THE UNITED STATES DOVERMENT STATE OF(..1 1 WRITERS."E� DnDFDmmCaD NDUL GE IEB TIG.REO RAND w THE MAYOR OF 9u00D Gi'V.0 T.CORPORATE SELL THEREOF I ". 15 wY NAY ,2023 I. ,I ga n e01s ATTEST wTE rL3S,2025 :AA'SF CNIC E P Qo �� R A. Y QA °E cn , , 0n°l� Up KKK _, 38069 f 4 ir D PD DpBaPkA B , PREaea �t' si ProBtoodborne .. By Pro T rainings Marshall Brown to education in Bloodborne Pathogens for Body and Tattoo Mists This course includes the following objectives and is consistent with OSHA Blood borne Pathogens Standard 29 CFR 1910.1030 and body art safety .Imeolro Control for Body kb. .Regulated wan« Nov Bloodborne Pathogens are spread -Body Fee « ,e.Cleanup nea 5 and AIDS -MOWS .6 Remo. Alepanto C V�rus and YecurM S olO tlon noced nn Sr Body An shop. Skin OHBA s Exposure Ind.ea aMPapaag -MMlrallsues W.Bod.A0 -Reducirg80t Eng.neenng and Wank Pram.Connote Gan CMaNn... CERTIFICATE NUMBER ❑e `.:gi10 ROY W.SMAW k100 5�•V OATS 5 TR564 Fr.- rr, 0- DATE ISSUED RENEW 8T %P. 02 May2024 02 May2025 Q ..':' ProCPR`' tato By ProTrainings PruTrainings hereby certifies Marshall Brown Mutt CPR/AED&First Aid This Certification includes the following objectives and is consistent with national consensus 2020 ECCALCOR and American Heart Association®Guidelines. -MNt CPR venal Precauhpm AED -[babe.Emegences Geeing Control •stroke -Mu30ulesGNemlIn(Unes -Bons -Romaning •BRes and Stings Shock Management -Magic Reactiorn Breathing Emergencies •Seizures Heart Attack -Heat and COW Emerge,cies -Chan.Canxiwu and Urcancious ROY W.SHAW alto WI• CERTIFICATENUMBER l]••16047005505041 01...,.❑a DATE ISSUED RENEW BY �"A ° `s 12 May 2023 22 Nay2025 'A' o,n 7e au. .,.,ot. -,AIR,Mr ARAM 8R-AN:7.7 Pr 9c..o , _ o..