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Home My WebLink AboutHDBA-24-070 Stanley tr. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-070 FEE: $55.00/Technician This is to Certify that Ellen Stanley 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 Holzvay, Clerk Eric Weston Laurance Venezia, DVM James G. Gar finer Direct ealth J- Or TOWN OF YARMOUTH Board f Health 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division • Fax(508) 760-3472 Tyne of Application 0 New 79 Renewal Application Fee(s): $160/Facility $55 /Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility v Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S PI tt �;, l K 1./g 4t/o'c 62 g Business Name &Ad ss . (4 cvi-yrto AA A- 0 Z ( .; ity 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: ,, FAtiA irtrit/i/ t(/ ( First Last Middle Initial (n 12_ 0/ D5ateAf BiithW & Gender Tax ID # (establishment only) regal Mailing Mdress ji,a,--r�weod Cd• 27--cr City State Zip I-2-0 -(0 - % cS, '— (pia,/ Phone Number Email Address 1 Created 1/24/21 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art technician license or permit? yles ❑No If yes, lease list the information below. Attac additional a s i necessary. CO v`(',v 20 21- 19 F-N -OCR U r `}- 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 ❑ 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. c u Full Name of Ap licant 51io/2 ./ re Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: cKr- CITY AND COUNTY OF DENVER �� J% DEPARTMENT OF EXCISE AND LICENSES %f 201 W COLFAX AVE DEPT ff2D6 ` DENVER,N (720)COLORADO 82740 Q TELEPHONE:(720)865-2740 SEAL INDIVIDUAL-PROFESSIONAL LICENSE POST IN CONSPICUOUS PLACE BUSINESS FILE NO.:2021-BEN-0007951 ISSUANCE DATE:10/02/2023 LICENSE TYPE:BODY ARTIST LICENSE C42 P:/ ,'4 LICENSE HOLDER:ELLEN STANLEY DATE OF BIRTH:06/20/1993 CONDITIONS If any thenx_x^-r rditions of Iicensure beyond the licensee's obligation to follow all provisions of the Colorado Revised Stal Derive: nicipal Code,Promulgated Rules or an other cd state or federal law: 4`AboveTh 3iniN! • Certificate of Training . . Awarded to r Ellen Stanley For successfully completing the OSHA Bloodborne Pathogens Training for Body Artists iabkaa-jg555a0 Sep 28,2023 Certificate Verification Number Issue Date(valid for tyear) verity at www.statefoodsafely.com(Verity y• Il9DENVER ohe lOMm Cln AboveTralhinglnc rn1)r MILE HIGH CItY Congratulations$ successfully completed the aboveTraining.coin Bloodborne Pathogens for Body Artists Training Program. Body Artist License ourse and lest are compliant watt OSHA standards.Please keep tins proof of tradong for your records 3ILITY TO RENEW PRIOR TO V THIS LICENSE.IT SHALL BE ;/r,/2// , HE EXPIRATION DATE UNLESS Director,Excise and Licenses PLETE RENEWAL APPLICATION THE W ALL LICENSELICENSE PRMLILL BEEGES WILL i'l1ki(.1\.fi-d:?j4-T.1,---- - Chef Financial Officer WED WITHIN 90 DAYS OF THE WITH ALL PROVISIONS OF THE `a"';' DE,INCLUDING COMPLIANCE IS A CONDITION OF THIS t ONLY THOSE ACTIVITIES ��/ _t, iOF DRIVER LICENSE , COMPLETION. 06/20/1993 `4r` IN RECOGNITION OF SUCCESSFUL COMPLETION IN: <" 08 308-0885 Standard-CPR/AED 1, 06/20/2026 (Adult/Child/infant) f.w KORBELIX Automated External Defibrillator(AED) ELLEN MARIE a ,114 WRIGHT 51 APT tt>7 'f"i._ ins CEFTIfLAT€d.Pxoutx4 Pessett-1, .. " - uxrwDDD co eons Ellen Stanley la The above mentioned Student is now certified in the above mentioned course by t 0emonstrab q proficiency In the subject by passing the examination in accordance with the b �� ® ®SaF nH¢5'-Ol' Ira fat-J Terms 6 Co dTons of National CPR Foundation-Valid for 2 years Course aomrmstered in y�„ti - Chia R ,. ,.Ss 04@212021 accordance with the 2020 ECGILCOR and AHA C guidelines. IDx TFD8D84 Completion-.April 29,2023 Instructor Paul).Scruten c.WRSE PPOVIEAD b, - n ( NatlonalCpRFmounc)atlon" Signature: � L �C