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Home My WebLink AboutKhristian BennettTHE CO NWEALTH OF MASSACHUSETTS TOWN OF YAR]T{OUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certifu fhAt Khristian Bennett at Spilt Milk January 1.2024, BOARD OF HEALTH:Hillnrd Boskev, M.D., Clnirnmn Mnra Crais. Vice Clnirnnn Clmrles Holioav, ClirkEic Weston Laurance Venezia, DVM (date) James Director of Health PERMIT NUMBER:# 24-002 HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in conformity with the authority ganted to the Board of Health, by Chapter 140, Sections 51, ofthe General Laws, and amendments thereto, and is subiect to the provisions ofihe taws ofthe Commonwealth ofMassachusetts relating thereto, and upon such lerms and coirditions, and to the rules and regulations in regard to the carrying on olthe occupation so licensed as adopted by the Board of Health. and expires December 31.2024 unless sooner revoked. TOWN OF YARMOUTH I I46 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.2445I Telephone (508) 398-2231, ext. 1241 Fax (50E) 760-3472 Type(s) ofBody Art: tr Tattoo Facility tr Piercing Facility ESTABLISHMENT INFORMATION Ddlattoo Technician tr Apprentice i Piercing Technician 6piluvr;tKTttffi L'lf (nu-k 2,{ Business Name & Address 0Lb73 rty State zip Type ofownership: D Sole Proprietor fi Corporation n Partnership If establishment is owned by a corporation, partnership, or other combination ofindividuals, please attach the name, title, tax ID#, and home address of all owners. Establishment Owner's / Technicians Name: Khrtsh'an georte#M First Last ttl tQ I +c, M Middle Initial Drlle oaBin6 Gender Tax ID # (establishment only) .9 Standtsh t t Legal Mailing Address ?rt v', ntu fuNr1 M+OZloZ City State zip t- 3tl rn n Email Address 1 ne Number 0 Crcated I D4D023 Tvoe of Aoolication [New p Renewal Application Fee(s): $160 / Facitity $55 / Technician $55 / Apprentice Board of Health Health Division PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art lqbigiq license or permit? list the information below. Attach additional pages if necesse f,des trNo Status (Active/Expired/Suspended)Sta unl ipality Lic./Cert./Reg. # State/lvlunicipality Lic./Cert../Reg. # Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? If yes, please list the information below. Attach additional pages ifnecessary. Status (Active/Expired/Suspended) ! Yes !No StatelN4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State/lvlunicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth trxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: Yes_No EMPLOYEE INFORMATION Please list and s all Arl Technicians ldtloo,rct lice Employee Name Type ofBody Art Performed 2 Crcated lD4n023 Requirements for Body Art Establishment Permit Submit the following to complete your application: n A copy ofowner's valid identification card with- picture (state-issued license, passport, or military-issued Io) tr Detailed floor and operation plans ofproposed body art establishment (new applicants only) D A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance tr Client application and consent forms n First Aid and CPR certifications ! Medical Waste Removal Contract ! Bloodbome Pathogen Training tr Aftercare information and instructions Applicant Statement of Consent Nam pplicant I understand that this permit is valid only in the Town of Yarmouth and expires at the etrd of the calendar year in wlich it was issued. I also understand that any notice to be mailed to me by the Torvn of iarmouth Board of Health witl be mailed to the address indicated on this application. I have received a copy ofthe 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 bf 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 certift, 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. Lhris tian btnnetc (q Lq Date It is your responsibility to renew your pernit at the end of each calendar year. 3 re Crciled 1 n4n023 THE COMMOI{WEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH at Snilt 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, SiiiiJni jt, of*re General Laws, and amendments therdtol and is subject to the pr.ovisions of'the.Laws ofthe brriri6"*6ittt' "f Massachusetts relating thereto, and upon such tedns and coirditions, and to the rules and r.-sr[ii;rlii ric".d io the carrying on ofthe occripation so licensed as adopted bythe Board ofHealth, and ex"pires Decembfr 3 l, 2023 unfess-sooner revoked Hillord Bosbctt, M.D., Chairman Mant Cmis- Virc Clmirmnn Charles Holionv, Cltrk DebraBruinooseEicWeston " Januarv 25.2023 BOARD OF HEALTH: (date) G. Murphy, MPH, R. Director of Health C PERMIT NUMBER: # 23-003 - FEE: $55.00/ rechnician This is to Certiry that Kristian Bennet