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Home My WebLink AboutJoseph GutshallTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certifo that Joseph Gutshall 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, 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 ofHealth, and expires December I l. 2024 unless sooner revoked. Hillard Boskey, M.D., Chairmnn Maru C rnis. ViceCltnirmnn Clmrles Hoki,av, Clirk Eic Weston Laurnnce Venezis, DVM Ianuary 1,2024, BOARD OF HEALTH: (date) *-/ .-,.. c n ^l' /James G. G Director of ilil;tllalth PERMIT NUMBER: #24-003 TOWN OF YARMOUTH Board of Health Health Division 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Telephone (508) 398-2231, ext. l24l Fa-r (508) 760-3472 Tvoe of Annlication [New p Renewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice Type(s) of Body Art: tr Tattoo Facility }pfattoo Technician tr Apprentice ! Piercing Facility tr Piercing Technician ESTABLISHMENT INFORMATTON 6piluit;tKT(tffi L'l[ fui*+t 2f Business Name & Address 0 L(o7 3 ty State zip Type of ownership: D Sole Proprietor fl Corporation tr 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: irst ast M Middle Initial o Genderirth Tax ID # (establishment only) J htr egal Address p City i s7 0q -zl T State Email zip 0 a/'/ 1 Phone Number 2 c.eated 1D412023 Ittl. url,rtnlu*h /14+ PRIOR T,ICENSTJRE Has the owner or operator ofthe proposed establishment ever held a body art technician license or permit? e lisl the ormation below. Attach crdditional pages if neces Pestl No S icipality Lic.l ./Re #Status (Active/Expired/Suspended) State/Municipality Lic./Cert.,/Reg. #Status (Active/Expired/Suspended) ! Yes nNo Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please list the information below. Attach additional pages ifnecessary. State,Municipality Lic./Cert./Reg. #Status (ActiveiExpired/Suspended) Please check appropriately ifpaid: Yes_No EMPLOYEE INFORMATION Please list and s qll Bo Art Technicians taltoo,terct ntice Employee Name Type ofBody Art Performed 2 State/Municipality Lic./Cert.iReg. # Status (Active/Expired./Suspended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. I Creaed 1D4n023 ! tr tr tr tr l tr tr I 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, passpor! or military-issued to) Detailed floor and operation plans of proposed body art establishment (new applicants only) A copy ofBlood Exposure Control Plan Proof of liability insurance / Worhnan's Comp. lnsurance 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 Ilealth will 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 inposed upon a licensed Body Art Establishment Owner/Operator by those regulations. I also agree to comply with all of the regulrtion requircments 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 Ilealth Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work practices regulations as spmilied in the Ysrmouth 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 ir complete and accurate and in no way misrepresented. Full Date It is your responsibility to nenew your permit at the end ofeach calendar year. 3 ture Crcated 1D4t2023 TIiE COVIMONW'EAI.TTI OF IVIASSACHUSETTS TOW}iOFYARMOUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certifu thrf osenh C al Spilt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in contbrmity with the authority granted to the Board of Health, by Chapter 1.10, Sections 5 I , 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 December 3 l, 2023 unless sooner revoked. January 25.2023 BOARD OF HEALTH Hillard Boskey, M.D., Chairman NInru Cn4g, Vice Clmirnum Cltttrles Holuav, clerK DebrnBruinooseEricWeston " (date) Bruce G. Murphy, MP Director of Health S.,HO PERMITNUMBER: # 23-004