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Home My WebLink AboutHDBA-24-068 Fowler THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-068 FEE: $55.00/Technician This is to Certify that Dustin Fowler 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 -7111111 C1h-� James G. Ga finer Direct ealth tryti, TOWN OF YARMOUTH Board of 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 712 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility /`- Tattoo Technician O Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S PI Lt Rkt • ieou.. .c Business Name&Ad ess 69ty. curbnA+k C1 (p�. ZipState 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: 7tL377)u/ First Last Middle Initial j/fs-- 74 , Date df Birt Gender Tax ID #(establishment only) a64/0 6/9/ Sr/ 34— Legal Mailing Address /3 /cL ', J //023 City / tate Zip c7/- /5-3 dv 5 #4 /kasfiye,42494f/ ea74 Phone Number Email Address 1 Created I/24/2022 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ❑ Yes technician license or permit? ❑ o If yes, lease 1' t t e information below. Attach additional pages if necessary. 4/ �, ` �/ 5/3/.y6 ft State/Muni ipality Lie./Cert./Reg. # Status (Active ' ed/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 //'l Signature Date / It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 ''"""'` DUSTIN FOWLER RM1 V �1 This certifies m that the person named above h completed the cognitive assessment of . \ t the folbwing I t natant CPR Institute co so Meets o exceeds OSHA standards "" = First Aid ...Ape..., ( ,� .,t�.,,�,\ DUSTIN FOWLER Completion Date:Nov/22/2022 • The cemees that the p rson named ttt nas Wrr pored the xp.r u assessment of the following International CPR institute course.Meets or exceeds OSHA standards Expiration Date:Nov/21/2024 Cert Num:999335 t•`!lull v'' k,.i Bloodborne Pathogens www.Instructor D1317 Cardholders Signature Completion Date:Jun/16/2023 Keep this card for your records.Void if reproducedIII Expiration Date:Jun/15/2024 Cert Num:1026375 Instructor D1317 Cardholder's Signature Keep this card for your records. Void if reproduced' NYC The City of New York Health Department of Health f I \ I i \IRIISI L itx n Nt• Record ID: Name: DUSTIN PAUL FOWLER Issued: 01/25/2023 Expires:01/31/2025 IMI1111111111 50 ;. r F,W YORK STAIN' r ' -:,--4 DRIVER LICENSE Io 651 811 711 _I355 D FOWLER DUSTIN,PAUL IIt 230 STOCKHOLM ST 3L v u BROOKLYN,NY 11237 ' ooe 07/15/1985 Issued 05/16/2023 Organ Exphes 07/15/2027 Donor E NONE y L P NONE {c,.... Sex M Height 5'-10' Eves BLU N�� i m C T N 5. m m n G a c 3t 9 ce m 0gmc it m„ c=i W/ ,�� 0, 'E m �E ,i a � m m a m V) W I.V cE.5$ v 7U < O �/ t— IVAOu 4 LL $ E m 0 W Z =mE m W Env m w 5 �'-E m S ❑ 0 }rl/ NF— _o o m $_ IS , o � m �❑ Z .g„ m > w N 5 0 w - _vs`o � m p 0 m1dr 2 z a (.) 8 2 l'c 5x5 O - oEa ¢ I— QQ mom N I-.Q 2 �Q 88 "r- _ d� & € _ a ‘'a 8-_ g 2 LL! "2 Tmb € As ado _ a a'¢ ' mN arno o * a X_ F tow F mm wo � a tr LT,mz .- 0 0 W W ao_ r ##°Kr* I'"ro l..P R CONTINUING EDUCATION EQUIVALENT TO d ''s` `• °O#° $AN0# RC I 34 TOA yF TICor,T Nu nC OUCA p N 6 PIOTreinings Adult CPR/AED Et First Aid 0 ;.1;j0 CL.:4r1E1L44;L NUMBER 168494733702555 Andrew Sharpe i _ ';S TRUCTCR DATE ISSUED RENEW BY ;4-1 F c ROY W.SHAW P100 24 May 2023 24 May 2025 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.protrainingscom support@protreinings.Com L ant? P rO B t o o d b 0 r n e CONTINUING EDUCATION EQUIVALENT TO 30 CLASSROOM HOURS Bloodborne Pathogens for Body and Tattoo ,• CERTIFICATE NUMBER Artists I 168494977702556 Andrew Sharpe ' 7 .i; i DATE ISSUEC RENEW BY ■ ..: 1 24 May 2023 24 May 2024 tiJ ROY W.SHAW#100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE EDUCATION IN OSHA BLOODBORNE PATHOGENS STANDARD 29 CFR 19101030 AND BODY ART SAFETY www.protrainingscom supportpeprotrainings.com L 7'�r, ` -, iVVI rvn N E V�`'�YO 1\i1 S TAI,E PURPOSES -- DRIVER LICENSE ,s 537 930 973 .-.,as,DM ��sy SHARPE ANDRE1h',F o, m 4r t. 304 BAYNES ST UPPR - 3 BUFFALO,NY 14213 ,, 4 " • y has 03/10!1987 Issued 01/0412024 ,M', a'' t,„ .,. Eyleres 03110f 2032 IF i "— E NONE E +" SRI M Height 5'-03' Eyes GRN