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Home My WebLink AboutHDBA-24-077 Shea THE COMMONWEALTH OF MASSACHUSETTS lr TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-077 FEE: $55.00/Technician This is to Certify that Sean Shea 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. ardiner Direct ealth t*-, TOWN OF YARMOUTH Board 11 1146 ROUTE 2.8JUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health 'Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 t .b gad LUL4 HEALTH DEPT • Type of Application 0 New 1711 Renewal Application Fee(s): $160 /Facility $55 /Technician $55 /Apprentice Type(s)of Body Art: 0 Tattoo Facility /`- Tattoo Technician ❑ Apprentice ❑ Piercing Facility ❑ Piercing Technician ESTABLISHMENT INFORMATION Sptt T:raZtr-O_O 4(17/C Business Name &Ad ess u((,urltOu +1 , 01Cv -4-,; ity State Zip Type of ownership: 0 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: (Sr RI . First Last Middle Initial Co I D too Birth Gender Tax ID # (establishment only) Cv\el.tiV VOOI& I Legal Mailing Address !IN � oqa go City State Zip 34H- 4Z2-6y32 Se Gun Sh -Frt+---po@a 041 Phone Number Email Address 1 Created 1/24/2023 PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art 'es technician license or permit? ❑No I yes ease ist the in ormation below. Attach additional pages if necessary. 19_ 0rSAP - 7021f- ► State/ unicipality 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? ❑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 • Created 1/24/2023 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 ❑ 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. ea__ Full Name of Applicant SZ ozIH `-�ignatu Date It is your responsibility to renew your permit at the end of each calendar year. 3 Created 1/24/2023 v, t r _._ . _ .... _ tAASSA �— ...._. _— t. / � .. �� yo� Commonwealth of Massachusetts 2su, ` • Eii Town of Orleans Dan ts'.r. 4 '"- " NEAL CII DEPARF'clI,f 2024 �el"it �.%e t9 School Rod Jan 01, �9gTE0 MAP l.trm Ocront No Orleans,MA0263,1 r124 I OF COMPLETION 508-249-37001,24100 BAP 2. Goo(dy's Tattoo IN RECOGNITION OF SUCCESSFUL COMPLETION IN: 64Main Street Bloodborne Pathogens ^^a'M Infectious Disease control Is IierebyGranted a Best Practices/Precautions Brody Art Practitioner License THIS CERTIFICATE IS PROUDLY psi NTFD:i 0 'Phis license is granted in confnrmitc with the statutes witl ordinances relating thereto-and Sean Shea e,pires on Des 31,2024 unless sooner suspended or resoled. Conditions(if any): Alcraadra Furl.meal, The above mentioned Student is now certified if,the above mentioned course by o,,,,wi Npp,,,,,.,In,: demonstrating proficiency in the subject by passing the examination in accordance with the x Mecaadn,phch Terms&Conditions of National CPR Foundation-Valid for 1 year.Course administered in accordance with the 2020 ECC/ILCOR and AHA guidelines. ID#.AE625763 Completion:January 26,2024 Instructor:Paull.Scruton 0 C PROVIDED BY. NationalnalGPRFoundation'• signature:Rdel...1_,.... ILII . ..j1 —.sr AIIIIIMMIIIIIMamm.—__ Certificate of Completion American Sean Shea Red Cross has completed the requirements for „ Ni a i n e NOT INTENDED 0� 1Q SecreCtry of Seliowate DRIVER'S LICENSE FOR FEDERAL Adult First Aid/CPR/AED Online :Ai Shnnna8050 to PURPOSES (Eligible for Skills Session within 90 ••i "EQ. . '4dOl-t,3 9176366 days) tit-. NI:.- 4t,Lx ,E5 06/1612024 3COIi06/1(I'1984 ,SHEA conducted by �.. `~� ,2 SEAN EVERETTE American Red Cross 0 • s 278 GREEN WOODS ROAD Date Completed: 12/27/2023 — PERU.ME 04290 Valid Period:2 Years Scan code or visit: 4a 15SUED 11/08/2022 15 0CNCIei M 16 11006HT. V'cREtC:HT 18 k. Certificate ID:01 DKMOP 5'-06" 175 lls Btu BRO '4 CLASS C 9a END L �DONk' https://www.redcross.org/take-a-class/gircode?certnumber=O <� f:i. 12R1isT B 1 DKMOP .gip`` 5 DD 5505000900000000094169327 ,4