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Home My WebLink AboutHDBA-24-069 Rodriguez CdTHE COMMONWEALTH OF MASSACHUSETTS J TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-069 FEE: $55.00/Technician This is to Certify that Justin Rodriguez 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. Ga iner Direct ealth ---�� OIL )4441. TOWN OF YARMOUTH Board of i Health it".:.44 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 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility l`- Tattoo Technician 0 Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S L-t- Nut I ahic 623 Business Name&Address epty i (il 0 IA OZ� -.2 iState 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: 7?4,/ A2Pis‹)/6;1,115 , First Last Middle Initial 30/97 /1)' Date f Birth Gender Tax ID#(establishment only) / 'h //D —R_ 57— / Legal Mailing Address '7S7/d/711)2()/1, 7) 1779 _3 2 O 6 City State Zip 95t/ 5/ daa y e /oo ibiev6Co r 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? ❑No If es, lease list the information below. Attach additional pages if necessary. State/Municipality Lic./Cert./Reg. # Status (Active xpired/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) El 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 El 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 .S_ 0 CJ-y ign ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 IV'ER4 LICE ,ea r RODRIGUEZ JUSTIN,LOUIS ,, A44ren ;_ 1414 WINDER ST RICHMOND,VA 232I0.6416 'ram+ e n n 46/36/1112 �/ a .a reu za ov - a- 1 Department of Professional and Occupational Regulation I EXPIRES ON ! NUMBER 9960 Mayland Drive,Suite 400,Richmond,VA 23233 11-30-2025 Telephone:(804)367-8500 1 1231001775 J BOARD FOR BARBERS AND COSMETOLOGY TATTOOER LICENSE DISPLAY IN PLAIN VIEW OF PUBLIC r JUSTIN LOUTS RODRIGUEZ IJ1IJLi v j)�--, r 9 W 31ST ST �J vll• � _. RICHMOND,VA 23225 M., t Status can be verified at httpi/wmv.dpor.virgin(a.gov _ _ j 1`iior --- - - DPOR-LIC(02.2017) IEEE REVERSE SIDE FOR PRIVILEGES AND INSTRUCTIONS) 1".11.4' l MED#G!r AMERICAN SAFETY6■ ( t)ErvIs nsi 1 ■fitstAid 1111111NEALTNINSTITUTE \,t - Joshua Mullins Atthommd inetnraor(Pont Name. 63551 Registry No. Justin Rodriguez 2/172023 2/2025 hea demonstrated ecgaa.eman of R,e required wee edge end headway Id Cass Completion Data EIprarpn Das evahiatax,{ai according la the cerageeon remnamaha of the naming program 804-517-1352 125575 adAaled belay. Treinfg Center Plan.No. Training Center I.D. 0 MU 0 ADE111011l11111F111 0 ABIAKIR1 0 AMt01rFA11 TNs AMA First Ad I CPR AED beanbag program conforms nits the 2020 Amartcet Heart AA.ociasen;AIIA)Curd.Mes Update far Canape tmonan Re.. talon and Eatengency Cedevaacate Can and ts.2020 MIA and Adelman Red Cross focused Update for ADULT FIRST A I D I CPR AED C8517A733 F St Ad T1rs neong program was not designed to meet pedutric tint ad tralneg requlrerreeM,and.houid not be used oar Ise Demme. Ewhabee data nowt not.stated two yore horn month of dam eosept.ean. CERTIFICATION Validation Code:C308988 63 8 1 5 28099 ( CARD Bloodborne Pathogens Joshua Mullins Authonzed Instructor{Pont Name) 63551 Justin Rodriyuez Regstry No has successfully completed the course requirements 08/17/2023 8/2024 for the Bfoodbome Pathogens Program. Class Camaro Date Fapeatn,Dow 804-517-1352 125575 Trarar g Censer Phone No Tranrq Center i.D MABICJII J j --�• 1 S T1TUTE The cad certifies the holder em cennpteted the souse requremronts as brooded by a almtnO Tt- FMaft a Sefwt HEALTH* Isu notFetl ASK h,islnwYdr Cel4Kahnn hoes not g�Avantse Myra pr'd_•nwr<v I:snpir tica+alrlr g4s.H8 S� Iltelttde MSTiTOTE or credentlskp Coven content awaits in sattanng this rMor stein and Iran-mg rerteaemam at the U S.OMata.enl of t-abor tOSHA 29 CFR 1010 1130.Cernf alge penal may not aereed 12 { months frau Date clargfianon