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Home My WebLink AboutJason HennTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH This is to Certi!that Jason Henn at Spilt Milk January 1,2024, BOARD OF HEALTH (date) James G. Director o rh PERMIT NUMBER: #24-008 FEE: $55.00/ Technician 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 relaling 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 31, 2024 unless sooner revoked. Hillnrd Boskcv, M.D., Chairmnn llnry Cra1g,lice Clmirnmn Chnrles t7olltifiV, Llerk Eic Weston Laurance Venezin, DVM TOWN OT YARMOUTH I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.24451 TelePhone (50E) 3 98'2231 , exL 1241 Fax (508) 760-3472 TVoe of Aoolication D New fl Renewal ApplicationFee(s): $150 i Facility $55 / Technician $55 /Apprcntice Type(s) ofBody Arr tr Tattoo Facility n Piercing Facility ESTABLISHMENT INITORMATION Snrutu;iL 0u/{ 18 BffissNail-& (o ity State Zlp Typo of ownenhip: tr Sole Proprietor tr Corporation tr Patuership 11 establishment is owned by a corporation, partnerstip, or other combination of individuals, please attach the name, title, tax ID#, and home address of all ovmers. Ertrblirhment Owner's / Techniciang Nemel ( Ja-s n ?hA ll/ First Last Middle Initial L000 of irth Tax #( l&Q c Slc,utns l ,rt ,d Tattoo Tecbnician tr APPrentice D Piercing Technician Legal Mailing Address S + State 0Z(?01 zip 7 ,sYt-c-hn Z I t Phone Board of Heehh Health Division &cdiln4tm2i BISUM Has the owner or operator ofthe proposed establishment ever held a body art !g@ig!gg license or permit? ease list the information below. Attach additio nal pages if necessary. unl ipality Lic./Cert./Reg. # &"" trNo v4_ Status (Active/Expired/Suspended) State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) O Yes trNo Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please lisl the information below. Attach additional pages ifnecessary. State/lvlunicipality Lic.iCert./Reg. #Status (Active/Expired/Suspended) State/I{turicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth trxes and liens must be paid prior to renewal or issurnce of your permits. No EMPLOYEE INFORMATION Please list and s all B tattoo,rc ntice Employee Name Type ofBody Art Performed 2 Crcsted I n4/2023 Please cheok appropriately ifpaid: Yes Art Technicians Requirementr for Body Art Establichment Pemit Subrnit the following to complete your application: tr A copy of owner's valid identificatiol car{ with. picture (stat6-issued license, Passport or military-issued to) tr Detailed floor and operation plans of proposed body art establishmeat (new rppllcentr only) E A copy ofBlood Exposure Cortrol Plan tr Proof of liability insurance / Workman's Comp. lnsurance n Client application and consent forms tr First Aid and CPR certificarions tr Mdical Waste Removal Contrsct tr Bloodbome Pathogen Training ! Aftercare information and instructions Appticant Statemetrt of Cotrsetrt I understud thrt thir pcrmit is valid only in the Town of Yamoutt snd erpires rt the end of the celendrr yerr in which it wes bsocd. I alro understrnd thrt rny notice to bo mdled to me by the Town of YarEouth Bolrd of lleatth wiII be meiled to the address lndicatcd on thir rpplicrtiotr. I have rcceived a copy of tte Yrrmouth Board of Health Body Art Regulrtionr- I have rerd end undergtend the obligrtions rnd requirementr imposcd upor a liccnrcd Body Art Ertrbtirhment (hvnerloperrtor by thore rtgulationr. I rko rgr€e to comply with ell- of the reguletion requirementr rpcctfed in the Yarmouth Bo.rd bf Hedth Body Art Rcgulattonr while prrctlcing in tbe Town of Yarmouth. I firrlter underg6nd that it is my rcrponsibillty to encure ttit indMdurl Body Art Tcchnicians worting in thir estrblirhment hlve I current valiil Yrmouth Board of lleeltt Body Art Tcchnlc-lan Licensc and comply with all appllcebte heelth, rafcty, ranitrtlon, rtcrilizetion, and work practico* rcgulrtionr rl speclf,ed ln tte Ysmoutr Board of Heelth Body Art Regulrtionr. Ihertbycertify,underpenaltiesandprinsofperiury'thsttothebertofnyknowledgethe iofor-i6oo p-riO.a on ttir apptication b compiete end accuretc end in no wey mirreprccented' Heh Full Name of APPlicrnt It lr your raponribitlty to r.cne|w your pemit rt tte cnd of eech celendar yerr. 3 Signaturc Cr..ed ll2Al2023 THE COMMOIVWEALTH OF MASSACIIUSETTS TOwlIOTYARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 23-013 FEE: $55.00/ epprentice This is to Certifu fhrt Jason Hehn at Soilt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODYART (TATTOOING) This License is issued in conformity with the authority gnnted to the Boad of Health, by Chaptsr 140, Sections 5 I , ofthe General Laws, antl amendments theretq and is subject to the provisions ofthe laws ofthe Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, and to the n es and regulations in regard to the carrying on ofthe occripation' so licensed as adopted by the iloard of Health, and ex-pires DecembEr 3 l, 2023 unfessiooner revoked. Januarv 30.2023 BOARD OF HEALTH:Hillard Boskea, M.D., Chairman Marv Crais. Vicc Chairman Charles Hoki,au, Clbk DebraBruinmpeEic Weston ' (date) { Bruce G. Murphy, MPH, Director of Health S