HomeMy WebLinkAboutDaniel TowerTHE MMONWEAL OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certil\r that Daniel Tower
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 ther€to, 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 31, 2024 unless sooner revoked.
Januarv 1,2024, BOARD OF HEALTH:
(date)
Hillnrd Bosktv, M.D., Chairnnn
Mant Crois. Vice Chnirnnn ClnrlesHoli,nv, CIerk
F,rir Weston
Laurance Venezia, DVM
4o.-," \cqrJ--J"."rG6;
Director of Health
PERMIT NUMBER: # 24-004
TOWN OF YARMOUTH Board of
Health
Health
Division
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
Telephone (508) 398-2231, ext. 1241
Fa-r (508) 760-3472
Tvne of Aonlication
[New p Renewal Application Fee(s): $160 i Facility $55 / Technician $55 / Apprentice
Type(s) ofBody Art: tr Tattoo Faciliry
tr Piercing Facility
ESTABLISHMENT INFORMATION
6Piltlrt;tKT(lffi
*rtattoo Technician D Apprentice
tr Piercing Technician
L'l[ (ru-k 2,(
Business Name & Address
0Lb73
State zip
Type ofownership: tr Sole Proprietor tr Corporation n Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the name, title, tax ID#, and home address of all owners.
Establishment Owner's / Technicians Name:
Danitl TOUJV F
ty
Firsl
4t-LI
Date fB
Last Middle Initial
Tax ID # (establishment only)
htl
Mailing A s
?fu^
State zip
q$-2L1Ll - tLqq loaK ln ancl /0,' "rdrr*/.rr*Email Address
1
Phone Number /"/
Cleated l/24D023
JK l)7b 5 7
City
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
!99@!g!gg license or permit?
.Yy""
trNoIfves. nlea^se list the information below. Attach additional naees ifnecessarv.-"rLlt'/ t t drtnll/ffi -u 23 - Do b Hc/7 rf
Stdtdr(luffcipaity Lic.iCert.lReg. #Status (Active/Expired/Suspended)
State/lifunicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art D Yes
g$Sb!!!EgS! license or permit? tr No
Ifyes, please list the information below. Attach additional pages ifnecessary.
State/lr4unicipality 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 all Art Technicians tattoo,terct rcect
Employee Name Type ofBody Art
Performed
)
Crcat d 1D412023
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)
tr Detailed floor and operation plans of proposed body art establishment (new applicants only)
I A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
tr First Aid and CPR certifications
tr Medical Waste Removal Contract
n 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 Health 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 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 certiff, 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.
1ant,I Tlwu
Full Name of Applicant
I I Z{L'{
Date
It is your responsibility to renew your permit at the end of each calendar year,
3
Signature
Created \ D412023
THE COMMONWEALTH OF MASSACHUSETTS
TOWNOFYARMOUTH
BOARD OF HEALTH
PERMITNUMBER: # 23-006 FEE: $55.00/ technician
This is to Certifu that Daniel Francis Tower
aL Soilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PLACTICE OF BODY ART (TATTOOING)
This License is issued in conlormity with the authority granted to the Board of Health. by Chapter 140,
Sections 5l, ofthe Ceneral Laws, and amendments thenito] and is subject to the provisions ofihe Lavvs ofthd
Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, 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' 31,2023 unless sooner revoked.
lamary 25.2023 BOARD OF HEALTH Hillard Boskev, M.D., Cluirtnan
Mnru Crais, Vice Clnirnnn ClmrbsHolioq, Clerk
DebrnBruinooge
Eric Weston -
(date)
Bruce G. M
Director of urphy, MP
Health
R.HO