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Home My WebLink AboutAaron JohnsonTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-005 FEE: $55.00/ Technician This is to Certifo that Aaron Johnson 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 of Heallh. and expires December 3l . 2024 unless sooner revoked. Januarv 1.2024. BOARD OF HEALTH: (date) Hillard Boskea, M.D., Clnirman Mnru Craip. ViceChnirmnn Clurles Holionv, Clirk Eric Weston Laurance Venezia, DVM esG.G r ofFI TOWN OF YARMOUTH Board of Health Health Division I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-2445I Telephone (508) 398-2231, ext. 1241 Fax (508) 760-3472 Tyoe of Aoolication frNew p Renewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice Type(s) ofBody Art: n Tattoo Facility tr Piercing Facility ESTABLISHMENT INFORMATION Dclattoo Technician D Apprentice tr Piercing Technician 6piltila;K Tltffi Ll[ ( nu-k 2,f Business Name & Address 0Lb73 ty State zip Type ofownership: n Sole Proprietor ! Corporation ! Partnership If establishment is owned by a corporation, partnership, or othel combination ofindividuals, please attach the name, title, tax ID#, and home address of all owners. Establishment Owner's / Technicians Name: Aantrt Jrhntort /a/L First Last Gender Middle Initial 2 B Tax ID # (estab t oniy) ,(_ I,E Mal SS Qrtut vilk lvc evg58 City State zip -+q q -asl I Phone Number Address J d Crcated 1124n023 I PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art technician license or permit? Ifves. olease list the information helow. Attach additional oapes ifnecessarv.imz'l ln^rmauJ-?t -tfL4 -n/b l1Dfl aWes nNor{ statuiiActi"elgipir-alsuspenaeal State/Municipality Lic./Cert./Reg. # 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. Status (Active/Expired./Suspended) D Yes nNo State,Municipality Lic.iCert./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 ifpaid: Yes_No EMPLOYEE INFORMATION Please list and s all B Arl Technicians oo,iercin a entice Employee Name Type ofBody Art Performed Creat d 1D412013 I 2 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, passpor! or military-issued Io) tr Detailed floor and operation plans ofproposed body art establishment (new applicants only) ! A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance ! Client application and consent forms ! First Aid and CPR certifications ! Medicai Waste Removal Contract fl 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 thaf 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 of the 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 specilied 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. Aartn Jahnsrtn Full Name of Applicant L Date It is your responsibility to renew your permit at the end of each calendar year, 3 Sign Cteat d lD4n023 (1,l THE COMMONWEALTH OF TOWN OF YARMOUTH BOARD OF HEALTH PERMITNUMBER: #23-016 FEE: $55.00/ Technician This is to Certift drat. Aaron Johnson al Spilt ilk 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, antl amendments thereto, and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating t}ereto, 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. February 17.2023 BOARD OF HEALTH:, Chairman (date)trtnan k rucc Director of Hea DebraEic