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Home My WebLink AboutHDBA-24-076 Johnson t(. THE COMMONWEALTH OF MASSACHUSETTS �i TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-076 FEE: $55.00/Technician This is to Certify that Nicholas Johnson 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 er Director of H alth ,i...:11 t 4\ 1151, TORN OF YARMOUTHBoard Health t t"...4.. i 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-2445 1 Health Telephone(508)398-2231,ext. 1241 Division " Fax(508)760-3472 Type of Application 0 New i9 Renewal Application Fee(s): $160/Facility $55/Technician $55/Apprentice Type(s)of Body Art: ❑Tattoo Facility V Tattoo Technician ❑ Apprentice ❑ Piercing Facility 0 Piercing Technician ESTABLISHMENT INFORMATION S pi l,-t mi( 0%, 9g a/71c 028 Business Name &Ad ss . ul aiffl 6 IA+if, IIA 4- 01 (40 -4-,3 City 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: A i ch D l as s khr?J'efl First Last Middle Initial VA /. ---- Date of Bi Gender Tax ID#(establishment only) /i a /1 e vs kd Legal Mailing Address is s p.e,K CAA- c>i y -s J ? City State Zip n z- q 14 c4e " n oh 0 s o n ' t 5-( 2) 44/. ceivv) Phone Nimbtr EmaL Address 1 Created 1rz4ri 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. State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) 6 4-- 2 1 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. d o1aS Jo ns Full Name of Ap licant 4-/ /zq igna d re Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/20: • (J(J1,f//(((f(JOF COMPLETION OF COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION iN. IN RECOGNITION OF SUCCESSFUL COMPLETION IN. Standard-first-Afd 8loodborne Pathogens Injury Prevention Inrec tiaus DiSease Contra! Universal Precautions Best Practices Pr'vc auttons Nicholas Johnson Nicholas Johnson the afro.. =ent onad Sruoent:S^ocv cen i:err.n the atm.e rn.nO cxrt'o r:U.:r-,e i!Y roe anore rnr''rt afneo St..nr-n i n•nit 0:1 V. tiorre lay rlenwntitrating Prarkraoty.+n the au-blest by pamd y the exarrteratior rn AScoidance with the ttf mof%trat 1g PrdErcr• 0,n,P0 mdaere'.t as'PAssrres the espm:natmn m occc+nOanee woo r' terms&COOd45On1 of National CPR Foundation Vnbd for 7 years.Course a:env:tSteree n Terms 6 Condkirin5 of Natonal CPR Founitd;rorr Va1Kt to 1 Mr.CtlurSp Ailot rv<). accordance yeah the 2020 ECCfLCOR and ANA yurdetme.. ItIa:1C64114 .ccordance wan the 2020€CUILCOR and ANA ourdetir.es me DOC96 Completion March 24,2024 Completion Marsh 26,2024 Instructor Paul J.SCNton Instructor Paul J.SCruten PR-Fos• Tn NabonaiCPRFountiaU m on" siyna .e ♦ NatlonalClCPRFountlatan' s ature t 1 .' ■ Body Artist Certification Z1SS 06/30/2025 (CertfiicAle Number) (E riaralmn DMei This certification is hereby granted to Nicholas Johnson (Artist Name) to practice Tattooing in conjunction with a permitted Body Art Studio. type of 0iody Art Proce tires'' This certification signifies compliance on the date of issue with the Rules of the Georgia Department of Public Health pursuant to the O.G.G.A 31-40-1 et seq.and is valid until the permit is revoked.suspended,or expires. 4 ,!TERREHS THLEEN E.T EY,M.D..t,k.Hj STATE DIRECTOR FNMTRONMENTAI,HEWN SECTION COMMISSIONER&STATE HEALTH OFI'tCi R DISPLAY FOR PUBLIC VIEW-NOT TRANSFERABLE-PROPERTY OF THE DEPARTMENT GEORGIA s Oldn'FR'S LCFNSE: COMMERCIAL DRIVER'S LICENSECr4.0,1 Governor Pl 1d DL NO.054921709 3 DOB 08/15/1985 9 CLASS A 4b EXP 08/1512027 4 2 NICHOLAS ADAM JOHNSON 5 1450 MATTHEWS RD JASPER,GA 30143-5912 o f PICKENS • 12 REST A 9:, END NONE k 4a Iss 10/16/2020 IS SEX M 18 EYES BL1J .€ 16 HOT 5' 10" 17 WOT 230 lb 5 DD 433010444710041681 V ORGAN DONOR