The URL can be used to link to this page

Home My WebLink AboutHDBA-24-067 Kelsey CO i THE COMMONWEALTH OF MASSACHUSETTS �V TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-067 FEE: $55.00/Technician This is to Certify that Collin Kelsey 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. rdiner Dir ealth „ 14 or flti- TOWN OF YARMOUTH Had°f 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 79 Renewal Application Fee(s): $160/Facility $55 /Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility 7d Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION Sp, 4c/o,c 8 Business Name &Ad ss City State Zip Type of ownership: ❑ 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: CO//1/7 J First Last, Middle Initial a(2 �/ at of ender Tax ID # (establishment only) ; (,ems IOs Pi. /U 5 Legal Mailing Address 0. 1--c( (i4- 3� ?I 2 - I YY�/ City State Zip Cf �- � �- -003q Phone Number Email Address • Created 1/24/21 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art es technician license or permit? ❑No I, 'yeas,p n se list t ee informatio b l . h additional pages if necessary. State unicipality 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 E 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 1/24/20 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. Cofim ia 9 Full Name of Applicantd 57/ol Z,7 Signature Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: JL National Health & '1r"' Safety Association ' Standard CPR/AED&First Aid(adult.child,infant) STUDENT Collin 1CelSey Course administered by the National Health& Safety Association following the 2020 ECC/ILCOR This card certifies that the individual has successfully and American Heart Association guidelines. completed the requirements accordance with the National Health&Safety Association curriculum. 466898-3941509598 For course details and CERTIFIED ON Mar 10,2023 VALID 2 YEAR ecerntcation,visit cpr o JL National Health -sr Safety Association 8loodborne Pathogens STUDENT Collin Kelsey Administered by the National Health&Safety Association following OSHA Bloodborne Pathogens This card certifies that the individual has successfully Standard 29 CFR 1910.1030. I completed the requirements in accordance with the National Health&Safety Association curriculum. 466898-3941499598 For course details and CERTIFIED ON Mar 15,2024 VALID 1 YEAR recertification.visit gx.io DEKAt: B COUNTY w Board of Health Division of Environmental Health March 14,2025 Body CrafterPermit BCA-888 Granted of Expiration to Permit Number COLLIN KELSEY Name of Body Crafter This permit signifies compliance on the date of issue pursuant to Chapter 13,Code of DeKalb County,GA,Sections 13-300 to 13-325,Article XI.This permit is to be renewed annually and expires 365 days from the date of issuance. 4W6,- 4/(11 z7l- Sandra Eliza rth Ford,M.D.,MBA.Director Ry r tra,MPH.Environmental Health DeKalb County Board of Health DeKalb County Board of Health Display for Public View-Not Transferable- Property of DeKalb County Board of Health GEORGIA DL Ln,It DRIVER'S LICENSE DRIVER'S LICENSE Governor?,'.Ql.— 4d DL NO.053700493 3 DOB 02/08/1991 9 CLASS CM 1n EXP 02/08/2028 2 COLLIN JAMES Ni \ 1 KELSEY `-. - �. .v 1 a 276 GLEN IRIS DR NE APT 3 ATLANTA,GA 30312-1444 c $, _:YAki . FULTON 4 €� - 12 REST A 4, 9, END NONE S ii4a Isis 12/05/2019 15 SEX M 18 EYES BRO 74_______, 16 HGT 6'-02" 17 WGT 190 lb 5 Dc 401434660810039106 V ORGAN DONOR