HomeMy WebLinkAboutMaxwell BlackmarTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YAR]I,{OUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifr that Maxwell Blackmar
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued ir: conformity with the authority gmnted 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 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 Health, and
expires December 31, 2024 unless sooner revoked.
Januaw 1,2024. BOARD OF HEALTH
(date)
Hillard Bosl<ev, M.D., Chnirman
Mara Crais. Vice Clnirnmn Clmrles
Holi,au, dirk
Eic Weston
Laurance Venezia, DVM
-.y'**"la,A":-'/ lu rt c. Gur)in../ Director o-nI/ealth
PERMIT NUMBER: #24-Oll
THE
PERMIT NUMBER: # 24-01I
OMMONWEALTH OF MASSACHUSETTS
TOWN OF YAR}{OUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu that Maxwell Blackmar
at
Jantary 1,2024. BOARD OF HEALTH:
(dare)
It Milk
Hillnrd Boskcv, M.D., Clnirnnn
Manr Crnis. Vice Chairnnn ClmrlesHoli,nv, A&kEic Weston
Laurnncc Venezia, DVM
-,y'o^*"la*A":-,7 James G
Director =-X*b#ealth
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 ofihe Laws ofthe
Commonweallh ofMassachusetts 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 Health, and
expires December 3l . 2024 unless sooner revoked.
TOWN OF YARMOUTH
RBibutE&, sourH YARMourH, MASsAcHUsErrs 02654-244s t
Telephone (50E) 39&2231, ext- l24l
I LB 0 8 2024 Fax (so8) 760-3472
Board of
Health
Health
Division
HEALTH DEPT,
Tvne of Anolicction
E New fl Renewal Applicuion Fee(s): $160 / Facility $55 / Technicirn $55 / Apprentice
Type(s) ofBody Art trTattoo Facility
o Piercing FacilitY
ESTABLISIIMENT INFOR,MATION
Snirt r\AilL 0uft{8
B*lEssNameE
7
State zip
Typc ofowncrrhip: tr Sole Proprietor tr Corporation tr Partnership
If establishment is owned by a corporatior\ partnership, or other combination of individuals, please
attach tho name, title, tax ID#, and homc address of all owners.
Esteblbhment Owner's / Technicisnr Name:
/Y\an*uu o/flrt tLtn
First Last Middle initial
qo
of Tax ID ishment
,d fattoo fecmician D APPrentice
tr Piercing Tectrnician
l.ntnr lm PI 6 zil-z
City State zip
EmailNumber
Cresfld ln4D023
I
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
!gg@!gb license or permit?
el 'st the informatio n bel Attacu+( gdditional pages if necessary.
/v.t
unicipality Lic./Cert./Reg. #
nNo
Status (Acti red/Suspended)
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 if necessary.
Status (Active/Expired/Suspended)
State/lVfunicipality 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 ifpaid: Yes
EMPI,OYEE INFORMATION
Please list and s all B tattoo,lerc lce
Type of Body Art
Performed
Employee Name
2
credted I D4n023
E Yes
trNo
No
Art Technicians
' Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
! Detailed floor and operation plans ofproposed body art establishment (new applicants only)
I A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
n Client application and consent forms
n First Aid and CPR certifications
! Medical Waste Removal Contract
! Bloodbome Pathogen Training
n 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 Yarmouth Board of Health will be mailed to the address indicated on this
application.
I have received a copy ofthe 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 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 provided on this application is complete and accurate and in no way misrepresented.
llMLma{
Full Name of Applicant
a
It is your responsibility to renew your permit at the end ofeach calendar vear.
3
ignatu
Crcat d lD4D073