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Home My WebLink AboutAlangil BergTHE COMMONWEALTH F ACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-006 FEE: $55.00/ Technician This is to Certifu that Alaneil Bers at Sn1It Milk January I ,2024, BOARD OF HEALTH:Hillard Boskey, M.D., Cluirmnn Mnru Crnis, Vice Chnirmnn CharlesHoli,ov, Clerk Eic Weston Lnurance Venezia, DVM (date) James G Director of Health 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 Heatth, by Chapter 140, Sections 51, ofthe General Laws, ani amendments therdto] and is subject to the provisions ofihe La'rws oftheCommonwealth ofMassachusetts relating thereto. and upon such terins and coidrtions, and to lhe rules andregulations in regar-d to thecarrying on ofthe occupation so licensed as adopted by the Board of Health, and expires December 31, 2024 unless sooner revoked. Board of Health Health Division I I46 ROUTE 28. SOUTH YARMOUTH. MASSACHUSETTS 02664.24451 Telephone (508) 398-2231. ext. I24l Fax (508) 760-3472 flNew p Renewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice Type(s) ofBody Art: tr Tattoo Facility tr Piercing Facility ES'IAELLSHI4 ENT INf ORIV!ATION 6pilttta;KT(lffi L'l[ fut*+t 2f dfattoo Technician D Apprentice tr Piercing Technician ln un"rm/u/-h /l/t A-0Lb+3 ei.r 7-State Zip Type of ownership: n Sole Proprietor n Corporation ! Partnership If establishment is owned by a corporation, partnership, or other combination ofindividuals, please attach the name. title. tax ID#, and home address ofall owners. Establishment Owner's / Technicians Name: irst ate f Birt Last Gender Middle Initial Tax ID # (establishment only) L5(oC Lo,r Ln SE Legal Mailing Address City tate rp -LILI F,mail Address 1 hone Number Created I /2{/2023 TOWN OF YARMOUTH Tr rre of Aprrlication Business Name & Address O Yes trNo StateA.{unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State,Municipality Lic.iCert./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) ! Yes nNo State/lrdunicipality Lic./Cert./Reg. # Please check appropriately ifpaid: Yes-No EMPLOYEE INFORMATION Please list and s,ct oll B Art Technicians ldltoo,terct entice Type ofBody Art Performed Employee Name 2 Cteated lD4D023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art !q[!gi4 license or permit? Ifyes, please list the information below. Altach additional pages ifnecessary. Status (Active/Expired/Suspended) State/Tv{unicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Requirements for Body Art Establishment Permit Submit the following to complete your application: D A copy ofowner's valid identification card with- picture (state-issued license, passpor! or military-issued to) tr Detailed floor and operation plans of proposed body art establishment (new applicants only) tr A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance ! Client application and consent forms D First Aid and CPR certifications tr 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 iarmouth Board of Health wilt be mailed to the address indicated on this application. I have received a copy ofthe Yarmouth Board of Heatth 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 specilied 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 certis, under penalties and pains of perjury, that to the best of my knowledge the information piovided on this application is complete and accurate and in no way misrepresented. Full N plicant q ,l ate Created \ n4n023 It is your responsibility to renew your permit at the end of each calendar year' 3 CO FMA CHI-TSE S TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #23-021 -FEE: $55.00/ recnnician This is to Certi$that.Alaneil Bers al Soilt tk 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 5 l, ofthe General Laws, and amendments thertito]and is subiect to the provisions ofihe Laws ofthd Commonwealth of Massachusens relating thereto. and upon such terins and coirditions, and to the rules andregulations in regar_d_ to-ti-e-carry ing on ofthe occupation so licensed as adopted bythe Board of Health, andexpires December 3 l, 2023 unlesslooner revoked. Februarv 17.2023 BOARD OF HEALTH:t"l (date) Director of Hea M,D Debra Eric