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Home My WebLink AboutJohn DenmatTHE COMMONWEALTH OF MAS A HU E TOWN OF YARMOUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certi!that John Denmat at SDilt 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 therelto] and is subject to the provisions ofihe l-aws ofthe Commonwealth ofMassachusetts relating lhereto, 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 31, 2024 unless sooner revoked. January I ,2024, BOARDOFHEALTH:Hillard Boslcey, M.D., Chnirman Maru Crnis. Vice Chnirman Chnrles Holzfiav, Clirk E'ic Weston Laurnnce Venezia, DVM (date) James G Director o Irh PERMIT NUMBER: #24-009 TOWN OT YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MASSACT{USETTS 02664.24451 Telephone (50E) 39E-2231'er& 1241 RECEIVEDFax (508) 760-3472 FtB 0 1 2024 Board of Heatth Health Division Tvoe of Aoolicetion E New fl Renewal ApplicationFee(s): $160/Facility .-...-.... $55 / Technicirn HEALTH DEPT $55 /Apprenticc Middle Initial Type(s) ofBody Art tr Tatloo Facility n Piercing FacilitY ESTABLISHMENT INF1ORMATION s 0uft 't8 Name & 7 State zip Ilpe of ownenhlp: tr Sole hoprietor tr Corporation tr Partn€rship 11 establishment is owned by a corporatioD, partnership, or other combination of individruls' plcase atbch ttre name, title, tax IU[, and home address of all owners. Ectsbllihment Owner'c / Techniciienr Neme: hn al First Last Tax ID rLS A Lbqq zipCState I 1 Tq Address CG,ri ln4n023 / Tattoo Techician tr APPrertict tr Piercing Technician ease list the nformalion below ach additional pages if necessary. y<* trNo s Sta cipality Ltc./Cert./Reg. # StateAvlunicipality Lic./Cert./Reg. #Status (ActivelExpired/Suspended) E Yes trNo IIas 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 dnecessary. State/I,Iunicipalit-v 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 s ct all B Art Technicians tattoo,rc ntice Employee Name Type ofBody Art Performed 2 Crcated I D4D023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art technicien license or permit? Status (Active/Expired/Suspended) Requiremenk for Body Art Establishment Permit Submit the following to complete your application: D A copy of owner's valid identification ca{ with- pictue (statriissued license' passport, or military-issued Io) tr Detailed floor and operation plans ofproposed body art establishmeat (new appllcantr only) E A copy ofBlood Exposure Contol Plan E Proof of liability insurance / Workman's Comp. Insurance tr Client application and consent forms ! First Aid and CPR certifications D Mgdical Waste Removal Contract tr Bloodbome Pathogen Training E Aftercare infonnation and instuctions Applic*nt Sf;atemcnt of Conscnt I understud thrt ttrir permit ir velid only tn the Town of Yarmouth rnd expires rt the end of the calendar yeer in wiich it wrc irlued. I atgo underutand thot any nodce to bc meild to me by thc Town of iamouth Board of Ilealth will be mdled to the rddre$ indieted on this rpplicrtion. I hrve rcceivcd r copy of tte Yeruoutt Board of Ecettb Body Art Regubtionr- I hrve rted end understand tle obligeuonr rnd rcquirements impored upon a licenrcd no!{ M EcAbtishnent Owtrer/Operrtor by thoie regulationr. I alro agrec to comply with all_ of the ."goL6bo requirementripecified in the Yrroouth Bosrd bf Hedth Body Art Regubtlono while prrctlcing in the Town of Yrmouth' I firrthcr uldentrnd that it is my responsibility to ensurc ttlt hdividual Body Att Technicians wol*ing il thir cstablilhment hrve a iurrent valiil Yrmouth Board of Hceltt Body Art Technhfan Licensc and comply with ell appticeble health, rafcty, renitation, rterilhrtion, and *"rr p-.tLo rtguletionr ei specttrod iu tte Yarmouth Board of Heelth Body Art Reguletionr. I heroby certify, uldor penalties rnd prinr of peturYr th3t to the bcct of my howlcdge the bfomrtion providcd on til;p5;fu, il compiac-eaa rccur.te rtrd itr no wry mirrcprteented' r/ DEAJ lcl ? It ir your responsibility to rcnew your pomit rt the end of each calendar year' Da 3 Full CEa&d 12ia2023 (l)J THE COMMONWEALTH OF MASSACHUSETTS TOWNOFYARMOUTH BOARD OF HEALTH FEE: $55.00i rechnician This is to Certifu that John Dermat ilt 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 thenito] and is subjectto the provisions ofihe Laws ofthe 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 3 l, 2023 unless sooner revoked. 25 ruce c.M (date) 202 BOARD OF HEALTH: B Director of urphy, MPH, R.S., Health o PERMITNUMBER: # 23-009 at Hillard Boskeu, M.D., Chairman Maru Crais. Vice Chairman Clurlzs Hol{oav, C:lirk DebraBruinoose E,ic Weston "