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Home My WebLink AboutSpilt MilkTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTII BOARD OF HEALTH PERMIT NUMBER: # 24-001 FEE: $ 160.00 for Business This is to Certifu that Spirt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OF BODY ART (TATTOOING) This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on ofthe occupation so licensed as adopted by the Board of Health, and expires December 31, 2024 unless sooner revoked. January 01,2024, BOARD OF HE.ALTH:Hillard Boskey, M.D., Clwirman Maru Criiq, Vice Chairnnn Cluiles Ho1ruay, Clerk Eic Weston lnurance Venezia, DVM (date) n'/o^-,. C,lt..'L-:- J^ .t d. Gardiner ) Direclor of Healthv TowN oT YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.2445I Telephone (50E) 39E-2231, ext 1241 Fax (508) 760-3472 Board of Health Health Division Tvoe of Aoolicrtion tr New fl Renewal Application Fee(s)150/F $55 / rechnicieo $ss /AppHEijEtVeO 7d Taroo Tectmician o Apprntice FEB 01 ?0?4 HEALTH DEPT Type(s) ofBody Art:tr Tattoo F Facility tr Piercing Technician ESTABLISHMENT INFORMATION SnlLt r\Ai l(0ul< ,28 Busiilass NameE ltJ vlrumov+h l\/ /.07bnL-Eity] re -zip Tlpe of ownenhip: tr Sole Proprietor tr Corporation D Partnership If establishmetrt is owaed by a corporatioq partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all owners. EstabliEhment Owner's / Technicians Namc: ['nug &rU'ss First Last Date Gender q frUadtat [1riqA /r, Middle Initial TaxID#( ?. Sa^d///ict)M*- City State zii 0 1 0b- I Address Cretu 1D4t2023 u- ttltzl+t tu\ ltt e list the infor on b"$ef,wrAtnch additional pages if necesJ, ilv"t trNo Status (Active/Expired/Suspended)S unlcipality Lic./Cert./Reg. # State/Ir,funicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) fr"'!No Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? I.fyes, please list the information below. Anach additional pages ifnecessary. Sta unicipality Lic./Cert./Reg. # fi** Status (Active/Expired/Suspended) State/Ivlunicipality Lic./Cert.iReg. # Town of Yarmouth taxes and liens must Status (Active/Expired/Suspended) e paid prior to renewal or issulnce of your permits. Ncr terct ntice Plcase check apprr-rpriately if paid: Ycs EMPLOYEE INFORMATION Please list and s all B,Art Technicians oo, Employee Name Type ofBody Art Performed 2 Crcated I D412023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art !g@igi4 license or permit? t6kl V trvm tj"o0 / Requirementr for Body Art Eshblishment Permit Submit the following to complete your applicatior: il A copy ofowner's valid identification card with pieture (state-issu€d license, passport or military-issued to) tr Detailed floor and operation plans ofproposed body art establishment (new applicrntr only) D A copy ofBlood Exposure Contol Plan n hoof of liability insurance / Workman's Comp. lnsurance ! Client apolicstion and conssnt foms D First Aid and CPR certifications tr Medical Waste Removal Contract ! BloodbomePathogenTraining ! Aftercare information and instructions Applicant Statement of Consent I underutand that this pemit lr valid only in the Town of Yamouth and erpirer at the end of the calendrr year in which it was issnod. I also undentand that eny noticc to bc mailed to me by the Town of Yarmouth Board of Health will be melled to the address indicrted on thi! spplimtior. I have rrceived a copy of the Yamouth Board of llcdth Body Art Reguletionc. I hwe rerd and underrtend the obligationc and rcquirement impored upon e licenscd Body Art Ertablishnent Owner/Operator by those regulations. I ako agree to comply with all of the rcgulation rcqulrementr specified in the Yamouth Board bf Health Body Art Reguhtlons while prrcticing in the Town of Yamouth. I fudter underotand that it is my responsibility to encurc thrt hdividual Body Art Technicianr working in thir establishment heve a currtnt valid Yatmouth Board of Healtt Body Art Technicirn License and comply with dl appliceble health, safety, senltation, sterilization, and work practicer rcgulrtionr as rpeclfied in the Yarmouth Board of Health Eody Aft Regulrtionr. I hereby certify, under pcnaltiea and pains ofperiury, that to the best ofmy knowledge the information pnovided on thir application ir complete and accurate and in no wry nirrepnerented. Date It ir your ruponsibility to rcnew your pcrmit !t the otrd of erch calendar yean 3 NFull *ct,rd llul2023 -- +".