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Home My WebLink AboutHDBA-24-074 Capwell THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-074 FEE: $55.00/Technician This is to Certify that Jasper Capwell 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, D VM James G. Gar finer �-- Direct ealth f'" _9 or . TOWN OF YARMOUTH H rd f 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 Tgi Renewal Application Fee(s): $160 /Facility $55/Technician $55/Apprentice Type(s)of Body Art: ❑Tattoo Facility (`- Tattoo Technician ❑ Apprentice ❑ Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION S pI t-t- A/c( oK -.. 4u-/'c. 98628 Business Name &Ad ss ) . rc,C►TI O IA+h AA - O 2 (i 3 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: t os tr CcLp First Last Middle Initial i/ 1A Da e of irth Gender Tax ID# (establishment only) 2-4 1 nO fia j Legal Mailing Address 01/ n Al 130/ /t / f i-/ef/Df- 13241 City State Zip -727 - 36/ -3 Phone Number Email Address • Created 1/24/21 PRIOR LICENSURE • Has the owner or operator of the proposed establishment ever held a body art es technician license or permit? CI No If yes,pl se list the information below. Attach additional pages if necessary. State unicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) rni ( jpsJcu'm hiq-o q37 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) 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 ❑ 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. Ja4pe4r C Full N me of Applicant Signature at It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: N -+a q ;? ._.— '_ '-'" `�-� Pel manent Ucenxe Nu(her 3tJS '" Grel h Whitman. fl co e,o, State of Michigan BA-01937 r4 li 1 Department of Health and Human Services I� ......7A 63 = ' r t ,. i; s~ 411L-P.1111 �, aoo � .lt 2 I E m 3 3oA D �m z Body Art Facility License o mmn an VALID ONLY AT LOCATION BELOW iqj 2>1 a= N n oa.m NO' CD x G 382 wa ,� D DEPOT TOWN TATTOO PARLOUR t A Z p n Owner WILLIAM R FALSETTA II a m 33 E CROSS ST - 'n SD CD YPSILANTI,MI 48198 i o„n, a m "CS rr r -0C Al -n v -'2* rum (p o= LICENSE IS DULY ISSUED UNDER THE LAWS OF THE STATE OF MICHIGAN r Q f Expiration Date:1213112024 "9 K - -.. CaO3 7u avoid alate foe+n renewing this license, must be on or before Deremb 0 L i :g m ::e.m4,—ram& rE Or41:1 F/ /-/ • ,fir' r_ --I . e OF COMPLETION Y C IN RECOGNITION OF SUCCESSFUL COMPLETION IN: Bloodborne Pathogens p Infectious Disease Control F Best Practices!Precautions soa oa roio.CEATeanAtt is manna,PAC-SEATED an g in it Jasper Capweli o cr in co 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 tic Ji - Terms&Conditions of National CPR Foundation-Valid for 1 year.Course administered in accordance with the 2020.ECCJILCOR and AHA guidelines IDs.AFC1ETEb Completion:May 4,2024 Instructor:Paul J.Scruton COUSSF PROADED Rat n � NationalCPRFoundation- Signature:I'� , L oT '. USA ENHANCED �� DRIVER LICENSE -= C 140 373 745 630 Iss 08-24-2020 DOB 08-12-1995 EXP 08-12-2024 JASPER ROBERT CAPWELL -+,i 2781 SEMINOLE RD 08-12-1995 ti-- ',-o ,r ANN ARBOR,MI 48108-1324 _; i ,,. Sex M Hyt 509 EyesBRO - Lic Type E,0 End NONE 't Restrictions NONE IIIIII '^ DONOR V DD 0092222715113 Mr07-e12012