HomeMy WebLinkAboutAnthony TurriniTHE MM AL
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-012 FEE: $55.00/ Technician
This is to Certifu that Anthonv Turrini
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 ofMassachusetls relating thereto, and upon such lerms and conditions. and to the rules and
regulations in regard to the carrying on ofthe occupation so licensed as adopted bythe Board ofHealth, and
expires December 31, 2024 unless sooner revoked.
Jantary 1,2024, BOARD OF HEAL'I'H:Hillnrd Boskey, M.D., Chnirmnn
Maru Crnis. Vice Chnirman ClwrlesHoli,av, ClirkEic Weston
Laurance Venezia, DVM
(date)
n/o^"- QG."[:-,t-\/ James G. Gardner/ Director of Health
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTI{ YARMOUTH, MASSACHUSEfiS 0266+2445I
RECE IVED Telephone (508) 39t-223t, cxt. 1241
Fax (50E) 760'3472
rr.B 08 2024
Board of
Health
Health
Division
Tvoe of AoolicrtionH E ALTH DEPT
oNew flRenewal ApplicationFee(s):$160 lFacility $Ss/Technicirn $Ss/Apprentlce
Type(s) of Body Art tr Tattoo Facility
n Pierting FacilitY
FSTABLISHMEIIT IIIFIORMATX}II
etJ q8 0uk '28
Name &
(?
ity State zip
Typc of ovnenhip: tr Sole Proprietor tr Corporation tr Paroership
If establishment is owned by a corporatior\ paftnership, or other combination of individuals, please
attach the name, title, tax nf#, aud home address of all owners.
Estrblhhmetrt Owner'c / Technicirnr NlEe:
*hon.ln
f tattoo tectmiciar tr Apprentic€
tr Piercing Technician
Middle Initial
ax ID onlY)
First
Date of
t+q
Last
N\
LI ht lt +
tt rl
tate zip
n @
nol't^ci lra
1
+-
Ct M lD4D023
PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art
!g@!!g license or permit?
lisl hei n below. Attach additional pages if necessary.
F'trNo
Sta unlcl ty Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #
Has the owner or operator ofthe proposed establishment ever held a body art
gg!g[!!q@! liccnse or permit?
Ifyes, please list the information below. Attach additional poges if necessary.
Status (Active/Expired/Suspended)
tr Yes
trNo
Statelr,lunicipality 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-No
Please list and Art Technicians Iattoo,tercl nticecr.
Type ofBody Art
Performed
2
Crc&Ed \n4D023
EMPLOYEE INFORMATION
all
Employee Name
Requirements for Body Art Estrblishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identihcation card with picture
(state-issued license, passport, or military-issued ro)
tr Detailed floor and operation plans of proposed body art establishment (new appticants only)
! A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
! First Aid and CPR certifications
n 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 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 specilied 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 certi$, 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.
Full Name of pp cant
I n
lzt4
Date
It is your responsibility to renew your permit at the end ofeach calendar year.
3
S tu re
Crcated 1 12412023