HomeMy WebLinkAboutMolly GotlibTIIE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-013 FEE: $55.00/ Technician
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 authonty 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 relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health, and
expires December 3 I , 2024 unless sooner revoked.
Jantarv 1.2024, BOARD OF HEALTH
(date)
Hillard Boskty, M.D., Clnirnnn
Mnnr Crnis. Vice Chnirmnn Chnrles
Hohi,nv, ClirkEic Weston
Laurnnce Venezia, DVM
-<y'o^.-,-\G, ^!-:-/ 1ilG.d,n..' Director of Health
This is to Certi& tlnt Mollv Gotlib
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.2445I
D E r- .- . ! . r . Teleohone (508) 39V2i231, ext l24l'\c\'ElvLiJ raxls6ayzoo-l+zz
FIB 0I 2024
Board of
Health
Health
Division
Tvoe of Annlicstion
nNew flRenewal ApplicationFee(s):$160/Facility $55/Technician $S5/Apprentice
Type(s) ofBody Art: n Tattoo Facitity f tattoo Technician tr Apprentice
tr Piercing Facility ! Piercing Technician
ESTABLISHMENT IN FORMATION
0ut< 18S
Name &
7
ty tate zip
Type of owncrship: 0 Sole hoprietor tr Corporation tr Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the name, title, tax ID#, and home address of all owners.
Establbhment Owner's / Technicians Name:
At-
Last Middle Initial
L/
Date Tax ID only)qq L.r nd bzrqh 0\LL@ilMillingIdGss V
State zip
b lo - 2Lt (" ' bsq{^)l*Email Address
L
Phone Number
CrerEi lD4n023
nmenls
/,+ lo onP
City
PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art fles!g[!ig license or permit? trNoIf y"s,ease list the in mation below. Attach additional if necessary.
0unicipality Lic ert./Reg. #Status (Active/Expired/Suspended)
State/lr4unicipality 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
E MPTOI(EE !Nr8EI44r-[8N
Please list and s all B Art Technicians tattoo tercl ntice
Type ofBody Art
Performed
Employee Name
2
Creabd 1/2412023
State/N,funicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art i Yes
establishment license or permit? tr No
If yes, please list the information below. Attach additional pages if necessary.
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
E A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued Io)
n Detailed floor and operation plans of proposed body art establishment (new applicants only)
n A copy ofBlood Exposure Contol Plan
tr Proof of liability insurance / Workman's Comp. Insurance
tr Client application and consent forms
! First Aid and CPR certifications
n Medical Waste Removal Conffact
! 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 specified in the Yarmouth Board of Heath 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 certifu, 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.
I
lican
/Z
Date
It is your responsibility to renew your permit at the end of each calendar year.
3
N
ture
Cr.ated 112412023