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Home My WebLink AboutHDBA-24-072 Armstrong C. fard THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-072 FEE: $55.00/Technician This is to Certify that Frank Armstrong 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 Jame G. Ga diner Director ealth or . . TOWN OF YARMOUTH Ha f lth 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 767 Tattoo Technician ❑ Apprentice 0 Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION Lt NAAK •/g a/(74C 028 Business Name &Ad ss tYState 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: First Last 1 Middle Initial Q / f at of Bi h Gender Tax ID#(establishment only) P1 ,Spo7)9s Legal Mailing Address .oi,Un j C �-i LfZ 101 i State Zip P {0 s I Uy --.l ns aiw' Phone Number Address 1 Created 1rz4ni PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art , Yes technician license or permit? / ❑No If 's rl ase list the infor ation below. ttach,dd'tional es i necessary. y� COe f v '' z�Z: -Bi— n Das I f� 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? 0 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, ap rentice) 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) 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 ❑ 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. %rCtnI1— Inn stall Full Name of Applicant 101.11<...111111111r,,,,ar Sig'a u'f '�� ate It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20 r Adult CPR/AED V168389995886499 Frank Armstrong r "+F ',ATE ISSUED RENEW RV y r4y r�y}N,,�}, INSTRUCTOR 32 May2023 12 May2025 �•�F'�•r+'-• MOlY W.91AW f300 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRNNINGS CURRICULUM AND THE 2020 AMERICAN HEARTASSOCNTIONA GUIDELINES www_pmiralr In N zcom supPort.e+pratralnings.com L J alle American Red Cross Certificate of Completion Frank Armstrong has successfully completed requirements for Bloodborne Pathogens Training Date Completed-12/1/2023 Validity Period 1 Years Conducted by'American Red Cross O�, O # E0..Rp';AIR3Tr.c,Lh cwE a wr-.wx.u-A�ReI�,sTwTnd,«+« «R,- i tiW qT KENTUCKYL-' DRIVER'S LICENSE NOT FOR REAL ID PURPOSES 't 10:)lN A01-509-237 ARMSTRONG .FRANK RYAN 347 PLUM SPRINGS ROAD > , BOWLING GREEN.KY 42101 .B01/16/1985 2bEXP 0211612026 ass 0 9AEND NONE ,2,tF9 NONEINN .< sCx M 16i4Gr s•10•• TB EYES BRO 4a1SS - License No: 2023-BFN-0058815 90 2022040.0047477R01111 RON 04/0612022 ortoW z Name: FRANK ARMSTRONG ( 7 / y"� ; J DOB: 01/16/1985 �e Liu L Expiration: 12/08/2024 U QX W This badge must be dearly displayed, and a copy of your license must be carried at all times while you are providing services.