HomeMy WebLinkAboutAndrea TashaTHE COMMONWEALIH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-001 FEE: $55.00/ Technician
This is to Certifu that Andrea Tasha
at S ilt 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 5l , ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe t aws 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 olHealth. and
expires December 3l , 2024 unless sooner revoked.
lanuary 1.2024, BOARD OF HEALTH Hillard Boskev, M.D., Chnirnan
Mant Crais. ViceClnirman ClwrlesHoli,aa, CferkEic Weston
Laurance Venezia, DVM
(date1
James G ner
Director of alth
TOWN OF YARMOUTH Board of
Health
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health
r"l"eh""'(s&?si)e78;3-23text'1241 RECETVED Division
FEB 0 1 2024
HEALTH DEPT
Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice
Tvoe of Aonlication
fJNew pRenewal
Type(s) ofBody Art: tr Tattoo Facility
n Piercing Facility
ESTABLISHMENT INFORMATION
D4attoo Technician n Apprentice
! Piercing Technician
6piluLiltK Tltffi L'([ fuiu,at 2/
Business Name & Address
0Lb+3
State zlp
Type of ownership: n Sole Proprietor ! 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 ofall owners.
Establishment Owner's / Technicians Namer
ty
frndfia- TaJha-
First
/0 t
ofB
Last
Gender
Middle Initial
Tax ID # (establishment only)
3 Cldnd.rth ;f
Legal Mailing Address
/n,tinu hrun AAk 0 Z(os 7
City State p
/.(trr
Email Address
1
P Number
t- 3 03 tafuoa-rts
Crcated lD4l202i
PRIOR LICENSURE
Has the owner or opemtor ofthe proposed establishment ever held a body art
@bigi8! license or permit?
pl,t the belovl. Attac additional pages if neces
'ffes
trNo
Status (Active/Expired/Suspended)S ty Lic.iCert./Reg. #
State/lr4unicipality Lic./Cert./Reg. #
Has the owner or operstor ofthe proposed establishment ever held a body art
gg4![q@! license or permit?
If yes, please list the information below. Attach additional pages if necessary.
Status (Active/Expired/Suspended)
E Yes
trNo
State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/S uspended)
StateMunicipality Lic./Cert./Reg. # Status (ActiveiExpired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately ifpaid: Yes-No
EMPLOYEE INFORMATION
Please list and all Art Technicians loo,erctn
Type ofBody Art
Performed
2
crcated ln4n023
Employee Name
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
! Detailed floor and op€ration plans of proposed body art establishment (new applicents only)
E A copy of Blood Exposue Control Plan
! Proof of liability insurance / Workman's Comp. lnsurance
n Client application and consent forms
! First Aid and CPR certifications
I Medical Waste Removal Contract
! Bloodbome Pathogen Training
tr 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 rny notice to be mailed to me by
the Town of Yarmouth Board of llealth will be mailed to the address indicated on this
application.
I have received a copy ofthe Yarmouth Board of llealth Body Art Regulations. I have read
and underrtand the obligations and requirements imposed upon a licenscd Body Art
Estrblishment Owner/Operator by those regulations. I also agree to comply with all of the
regulation requirements specitied in the Yarmouth Board of Health Body Art Regulations
while practicing in the Town of Yarmouth.
I further undentand that it is my responsibility to ensure that individual Body Art Technicians
working in this establishment haye a currcnt valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, sanitation, sterilization, and
work practices regulations as specified iu the Yarmouth Board of Health Body Art
Regulatiotrs.
I hereby certify, under pensltie 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.
knfu<u / fasha-
Name of Applicant
4(I
It is your responsibilify to nenew your permit at the end ofeach calendar year.
3
Ct at d 112412023
I rl:
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTII
DEDf,/ll''I- ]\II II\/,IDED. 4 ]? NN?FEE: $55.00/ rechnician
This is to Certifr thar Andrea X Tasha
at Soilt t\tilk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATIOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 5 l, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth ofMassachusetts 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 Dcccmber 3 I, 2023 unless sooner revoked.
lanuxv25.2023 BOARDOFHEALTH:Hillmd Bosl<ev, M,D., Clnimmn
Mnnt Crais. Vice Auirman Clnrles
Holi,av, Cfirk
DebraBruinooseEic Weston '
ceC.M
(date)
Director of
urphy, MPH,
Health