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Home My WebLink AboutHDBA-24-071 Nielsen C' / THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-071 FEE: $55.00/Technician This is to Certify that David Nielsen 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. Gar finer Direct ealth OIF kik TOWN OF YARMOUTH Board 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division p Fax(508) 760-3472 Type of Application ❑New 79 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: ❑Tattoo Facility /`- Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION pi Lt r{7(0t20._ 4a71c ,i2g Business Name &Addkss ' . �c �O �- M 1\A c� Z� -.; rty State 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/'Technicians Name: OCW 01 &iI -e, 1 First Last Middle Initial 2 3 - -9 D too Birth Gender Tax ID #(establishment only) ii+41 rOP Legal Mailing Address WGrb i1� 6 ( �C(D —z&JO City �� State Zip �6 3 - 5- 4 i y3 OO,w-e t n� Jso,4 t tiros - CQr� Phone Number Email Ad s 1 Created 1/24/21 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ,,3'Yes technician license or permit? ❑No If��plej� theinformation below. Attach additional pages if necessary. 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 1/24/20 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. hid N/ds e� Full Name of A plicant %nature ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: (_:76ieate OF COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION IN: CPR/AED/First-Aid (Adult/Child I Infant/Choking) AED I Injury&Universal Precautions David M Nielsen (1 n neettCut L11 ;4'F, d LAC le SF The above mentioned Student is now certified in the above mentioned course by •} �+ demonstrating proficiency in the subject by passing the examination in accordance with the L,t) ITerms&Conditions of National CPR Foundation-Valid for 2 years.Course administered in L. - accordance with the 2020 ECC/ILCOR and AHA guidelines. 10#:793E7D4y.e' Completion:April 18,2024 v. 1`-,.,6)i p"7 its D Instructor:Paul J.Scruton U2103/1979 NON! COUASE PA OVID oD ay. 0210312027 NationalCPRFRFoundation" Signature: L 02/17/2021 tl 6 ua NIELSEN DAVID MICHAEL 13 WINTHROP AVE ; ,✓_ WATERBURY.CT 06706.2610 .jam American Red Cross T 'framing Service,- Certificate of Completion david nielsen has successfully completed requirements for Bloodborne Pathogens Training for Tattoo Artists Date Completed:12/7/2023 Validity Period:1 Years Conducted by:American Fled Cross ❑1`{' verily tendon.uan code or vKa recicress ragralg....ale ana ente-it "Fl a 4. 11. pr . ,earn ax,e maple,'acn m esa. u,.a,n 7;, it■ Dear Licensed Professional: This is your validated license for the coming year. Should you have any questions about your license,please email oplc.dph@ct.gov. Department of Public Health P.O.Box 340308 .--- ---- Hartford,CT 061340308 STA l L OP I.°NSEC I Icc ct.gov/dph/license DEPART AIesA OF PUBLIC HEALTH N,l„ ,. _rF.r Sincerely, v4 nna•noNNO , T rRRr :,, 2I185054 uTY6w rt. RR,02/28/2026PROMSSION Tattoo Technician Manisha Juthani,MD '+'•- =� -- i Commissioner l n'NuN� CONIMIWONER ',fATE OF CONNECTICUT I E8&tIYNivr of Pt.-RI.fe lLFMTli .:_. THE INDIVIDUAL NAMED BELOW IS LICENSED BY THIS DEPARTMENT AS A -Tattoo Technician ACTIVE ., .. uCa:g Na 26 • toxxt VT I nroir,,x STATE OF CONNECTICUT DAVIT)NIELSEN 02/28/2026 DEPARTMENT OF PUBLIC HEALTH NAVY ` u ono+ orcrt „r. 21185054 ME W n:RRen-tnluwp11 I I 21185059 26 02/28/2026 LTT II MG-NATURE Cool. AM ON. 1+f M(:N 1TU'RE CIZIISSIONER