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Home My WebLink AboutHDBA-24-073 Sanoca THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-073 FEE: $55.00/Technician This is to Certify that Nicholas Sanoca 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. Gar aner fizi&D Director of Health ply `' !'i TOWN OF YARMOUTH Board of Healt 1111 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 Type of 4pplication ❑New yi 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 S tt Akt �K Ltg 4U71C 67g Business Name&Ad ss r,Lirvt o u-14 >IA A— O Z cv -4--,3 City State Zip Type of ownership: ❑Sole Proprietor ❑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/'t:echnicians Name: ) t , ,, ( ‘ First Last Middle Initial Date of Birth Gender Tax ID#(establishment only) 11j - Legal Mailing Address Pt cU nt-rek Aij 0 7--of0 -2 6 City State Zip ff . L, 6y _ 7 $ Phone Number Email Address 1 Created 1/24/2 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art es technician license or permit? ❑No If yes,please list the information below. Attach additional pages if necessary. tate/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) lY)/trd0 66 752_ /179" State 'cipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Has the owner or operator of the proposed establishment ever held a body art 0 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 ❑ Bloodbome 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. NIcoo Cis SCVd�� Full Name of Applicant IA re Da It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: fr ,5 r �` ( )),IØ(s(ff(COMPLETION _ OF COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION IN: IN RECOGNITION OF SUCCESSFUL COMPLETION IN: eloodbome Pathogens CPR/AED/First-Aid infectious Disease Control (Adult t Child r Infant I Chokongl Best Practices t Precautions AED I Injury E.Universal Precautions Nicholas Savoca Nicholas Savoca The above tioned Student is now rtif:ed in the above mentioned course by The above mentioned Student is now certified in the above mentioned course tir demonstrating proficiency.n the subject by passing the examination in accordance with the demonstrating proficiency in the subject by passing the examination in accordance with the Terms E Conditions of National CPR Foundation Valid for 1 year.Course administered to Terms&Conditions of National CPR Foonuatti 1-Wild for yen,:Course ado f roistered In accordance with the 2020 ECC/ILCOR and ASA.guidelines. IGO855C4F8 accordance with the 2020 ECCnLCOR and AimA-guidelines IEO-1C22638 Completion-Apra 11,2024 Completion'.Apra 11,2023 Instructor'Paul).Scruton Instructor Paul J.Scruton :iiED at v cowiE PR OvTED H, / NationalCPRFoundation Signature:�A1 �, NationalCPRFoundation signature:ALI aid l imimmiritiiiiiimiiiiiimiiiiiiiimiziaiitwo HUNTERDON COUNTY HEALTH DEPARTMENT SANITARY INSPECTION REPORT k-'o\ Xv() !teA\c o 9- is CeilV4 t Name of Establishment Address SATISFACTORY DETAILED SUPPORTING DATA SHEETS ARE AVAILABLE UPON REQUEST ON T t'IESE PREMISES AND AT THE HUNTERDON COUNTY HEALTH DEPARTMENT HUNTERDON COUNTY HEALTH DEPARTMENT 314 Stale Route 12 County Complex,Bldg.#1,Suite 200 PO Box 2900 Flemington,New Jersey 08822-2900 (908)788-1351 NAIvfE INSPECTING OFFICIAALII((-Print) DATE 6 'C7 / �j�Y'tC� PERM NE REG.NO. SI E OFF INSPECTING O FICIAL NOT, Ih the State Sanita7 Code.Ines PlacaN shall De posted in a conspicuous pace near the public entrance of the establishment Sp emit references in the Oelaa Data Sheets are to N.J.A.C.B'Y"f"'ePl 2"1 c o i^iI Fa 5 i,iui . ...nar r/,,^D:r.r.-��J IL_.f-1CaCr Fi'3t lt"F7n1A.C+76 Fil q NE'WJERSEY LMvc AUTOARWER LICENSE NOT FOR"REAL ID"PURPOSES ' 92 LASS D iss 07-05-2022 r% 13 Dot;06S0-0'J-19936159071 06935 exti 06-09-2026 am VO NICHOLSACA A 132 IW STRS J E E T S.PLAINFIELD,NJ 07080-2150 END NONE *S' "` ,s RESTR NONE f GENDER M HGT 5 07" E'r1 S HZL r 4VV 5W202218600003060 REN 24.00