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Home My WebLink AboutHDBA-24-075 Davis THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-075 FEE: $55.00/Technician This is to Certify that _ Richard Davis 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 Holzuay, Clerk Eric Weston Laurance Venezia, DVM James G.Gar ner Director of Health 0r. TOWN OF YARMOUTH Board of i1 Health 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 r" Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: 0 Tattoo Facility /S Tattoo Technician ❑ Apprentice 0 Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION I of y-/c 028 Business Name&Ad ss . (Dien () 1(-- +,State 0 (p ,3 ttY p 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: C11cord Pcw First Last Middle Initial f 1 117 3 . Date f B Gender Tax ID#(establishment only) Q6 'oil Legal Mailing Address V 1 lla 3 / K - 33 / ? City State Zip Nia_ .)-ectivtifo 9444 0,1 I. cekh Phone Number Email Addre s 1 Created 1/24/2 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art ›qes technician 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/M 'cipality 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: O A copy of owner's valid identification card with picture (state-issued license,passport, or military-issued ID) C1 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 O First Aid and CPR certifications O 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. K Ortvis Full Name of Applicant SI/ 3 / igna e Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20" .......___ ___..... _ ......„...,,,, .. „,,,,.._ r ,i,,,,, II .9`-/+ "�"L� OF COMPLETION zate OF COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION IN' IN RECOGNITION OF SUCCESSFUL COMPLETION IN: Bloodborne Pathogens CPR/AED/First-Aid Infectious Disease Control (Adult/Child!Infant/Choking) Best Practices/Precautions AED/Injury&Universal Precautions ,-...,,,.,,,,,it s-R;.ro rnesrn:eti ty _ acERur£is t Richard Davis Richard Davis The above mentioned Student is now certified in the above tnenboned course by demonstrating proficiency in the subject by passing the examination in accordance with tn.: Terms&Conditions cf Natrona:CPC Foundation-Valid for I year.Course administered n ' The above mentioned Student is now certified in the above mentioned course by accordance with the 2020 ECUILCOP and AHA guidelines. !DO 693CFD • demonstrating proficiency in the subject by passing the examination in accordance with the Terms&Conditions of National CPR Foundation-Valid for 2 years.Course administered in completion:March 5,2024 accordance with the 2020 ECC/ILCOR and AHA guidelines. 10a:5ECB13C Instructor:Paul/.Scruton COURSE Pa0,3E0RFO BY n 0 r, Completion:March 5,2024 ®HatJOnaICPRFoundati0rl' Signature.1� -�/w Instructor:Paul J.ScrutonL. at rnal PPrRFECi8r. _ n /� ... ±u NatjanalCPRFoundatjon' signature:/� (//J}U�/.--..... T 1 10 a ■ ' I i Ar ■ I r Body Artist Certification 2110 .i,a.,zs f {CwrInme Numb,' ffnpuarwn bath This certification is hereby granted to Richard Davis 1 to practice _- _ ._____ Tattoa^�____—_______.___-_.._. in conjunction with a permitted Body Art Studio (New a Body Ad Procedures) 1 !his cert!Lcabon signifies comp:rance on the date of issue with the Rules of the Georgia Department of Public Heath pursuant to the 0 G G.A 31-40-1 et seq and is valid anti the permit is revoked,suspended,or expires { 1 / GALEN C.BAXTER,REHS KATHLEEN E-TD M.D...M�9.ly r stet DEREC`txt ENVIRONMEN,A;HEaLn mCnOri Cdme.4SMostR&SIMI MEA.1M fKCICER i , DISPLAY FOR PUBLIC VIEW•NOT TRANSFERABLE-PROPERTY OF THE DEPARTMENT I DRIVER'S LICENSE ra_h.,.r..2. 1 DL NO.036586727 DOB 11/19/1973 1 E xr 11/19/2026 RICNf,a,L,TERRELL 4290 Cc,�F 2D l lit'.Li,P.!;..- GA 30180-3349 t..n.,tr`r..:J Restrict 1414 ionsA End NONE Iss 10/31/2018 t _..— - Sex M Eyes GRY -6� "r - -----) Hgt 5'-09" Wgt 175 lb rDD t 361431306320044406