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Home My WebLink AboutMark CorlissTHE C MMON EALTH OF MASSACHUSETTS TOWN OP YARMOUTII BOARD OF HEALTH FEE: $55.00i Technician This is to Certifu that Mark Corliss 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 5l , ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe Commonwealth of Massachusetls 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 bythe Board of Health, and expires December 3l, 2024 unless sooner revoked. Jantarv 1.2024. BOARD OF HEALTH Hillard Boskey, M.D., Chnirmnn Mnra Crnis. Vice Clmirnnn CharlesHol ,nv, CTe* EicWeston Laurnnce Venezin, DVM (date) 4.*-"^ea.-L:-L".".c-il,r>; Director of FIEdlih PERMIT NUMBER: #24-007 TOWN OF YARMOUTTI Board of Health Division 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 026&-24451 Health Telephone (508) 398-2231, ext, 1241 Fax (508) 760-3472 RECEUED FEB O1?O?4 HEALTH DEPTTvoe of Anolication ! New fl Renewal Application Fee(s): $160 i Fecility s55/T $55 / Apprentice Type(s) of Body Art: o Tanoo Facility n Piercing Facility ESTABLISHMENT INFORMATION s 0ulc {8 Name & [tJ vrumoil+h ^AkEity I . stat€ -zip Type of ownerrhip: tr Sole Proprietor tr Corporarion tr Paffi€rship If establishment is owned by a corporatioq partuership, or other combiration of individuals, please attach the name, title, tax ID#, and home address of all owtrers. Estnblishment Owner's / Technicians Name: (lvrr furU ss L ,dTatooTechician D Apprentice tr Piercing Technician (t7(o?z First Last L IL +? B 5 fv)tarlotil |gn/tct 0{, axID#( Middle Initial only) Legal lvfailing Addrcd U & State Z p I Email L Phone arh Cftdrn W4n02i A riJ,Ji nmen PRIOR LICENSURE Har the owaer or operator ofthe propwd establishment ever held a body art technicien license or permit? list the on Attach-b additional pages if necessary. Lic./Cert./Reg. #Status (Acti F9""trNo uspended) s Lic./Cert./Reg. #Status (Active/Expired/Suspended) Has the osrrer or operstor of the proposed ertablirhrnent wer held a body ert cstrblishment [ccue or permit? If yl please list the infomation below. Attach additional pages ifnecessary. O Yes trNo State/}ilunicipality Lic./Cert./Reg. #Status (Active/Expircd/Suspended) Stste/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) Town of Yarmouth tsres snd liem must be paid prior to renewd or issuance of your permits. Please check ap,propriately ifpaid: Yes_No EMPLOYEE INFORMATION Please list and all Art Technicians Employee Name Type ofBody Art Performed 2 cfas,.ed, llUl2U23 Requirementr for Body Art Establishment Petmit Submit the following to complete your application: D A copy ofowner's valid identifrcstion card with picture (sate-issued lieense, passpo$ or military-issued to) tr Detailed floor and operation plans of propos€d body art establishment (new appllcrntr only) E Acopy ofBlood Exposure Contol Plan E Proof of liability insurance / Workman's Comp. Insurance n Client application and consent forms n First Aid and CPR certifications n Mgdi""l Waste Removal Conhact n BloodbomeParhogenTraining tr Aftercare information and instructions Appiicart Statement of Consent I undergtrnd thrt this pcrmlt is valid onty in the Town of Yamouth and erpires rt thc end of the calendar yerr ln which it was issued. I also understud Oat eny notice to be mailed to me by the Town of Yarmouth Board of llealth wiII be meiled to the addregs indicttcd on thil application. I have recefued a copy ofthe Ysrnouth Board of Eealth Body Ari Regulrtions. I hrve rcad and understand the obligations end rtquirementc imposed upor a licenscd Body Art Ertrblirhmetrt Owner/Operrtor by those rcgulations. I elro agree to comply with all of the rrguletion rcquircments specified in the Yrrmouth Bosrd bf Hedth Body Art Regulationr while prrctlcing in thc Town of Yamouth. I firrthcr understsnd that it is my responsibility to emrre ttrt hdMdual Body Art Technicianr worting in thir establichnent hrve a current vdid Yamouth Board of lledth Body Art Techician Licence and comply with ell appllcable hcalth, safety, srnitatlon, sterilizetion, and work practices reguhtione es specifed in the Yarmouth Board of Health Body Art Regulations. I hcreby certify, urder penaltier and prins of perjury, that to &e best of my knowledge the infomrtion provided on thir application ir complete ead accurate and in no vay miercprcss1lsd. Name of. q Z I It lr your responsibility to nensw your llermit rt the erd of each cdendar yean creat9d lluD(n3 3 THE COMMONWEALTII OF MASSACIIUSETTS TOWN OF YARMOUTH BOARD OF HEALTH FEE: $55.00/ rechnician This is to Certi!that Marh Corliss at Spilt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in confolnrity with the authurity grantcd to the Board of Health, by Chapter 140, Sections 5 I , 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 tothe carrying on of tie occupation so licensed as adopted bythe Board ofHealth, and expires December 3 l, 2023 unless sooner revoked. Hillnrd Bosl<ev, M.D., Chairman Mnrv Cr is.ViceChtirnut Aa es Hoki,w, Abrk DebrnBruinoose Eic Weston " Jarnary 25.2023 BOARD OF HEALTH: (date) Bruce G. Murphy, MPH, R.S Director of Health o PERMITNUMBER: # 23-002