HomeMy WebLinkAboutJohn MattersTHE COMMO F MASSACHUSETTS
TOWN OF YAR.I\,{OUTH
BOARD OF HEALTH
FEE: S55.00/ Technician
This is to Certifr Joho M
at Srril t 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, oftheGeneral Laws, and amendments therdto] and is subject to the provisions ofihe Lai,'rs ofthdCommonwealth of Massachusetts relatLng thereto, and upon such terrns and coirditions, and to the rules and
regulations in rggar-d, to-th-e carrying on ofthe occupationso licensed as adopted by the Board of Health. andexpires December 31,2024 unless sooner revoked.
Januarv .2024.BOARD OF HEALTH: HillardBoskey, M.D., Cluirman
Maru Crois, Vice Chairmnn Charles
Holzi,av, C[erkEic Weston
Laurance Venezia, DVM
(date)
James
PERMIT NUMBER: # 24-014
th'r
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 0266/.24451
REe EIVE[] T.lenhond50t)r39E-22301, ext. 1241
Board of
Health
Heatth
Division
FtB 08 20?4
rvne ofAoolicrton HEALTH DEPT.
ONew flRenewal ApplicatioaFee(s):$16{l/Faclltty S55/Technicirn $Ss/Apprentice
Type(s) ofBody Arl trTattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INtrON.MATION
,d Tattoo Technician tr APPrentice
D Piercing Tecbnician
q8 0u/< {8s
Name &
(?
ity
Typc of owncrship: D Sole Proprietor tr Corporation tr Partn€rship
If establishment is owned by a corporation, partuership, or other combination of individuals' please
attach the name, title, tax ID#, and home address of all owners'
Ectablbhnent Owner's / Technlcisnr Nrme:
Last Middle Initial
Tax ID
2-tTt)K
Legal
Rl
(*4q
State zip
Ll
N
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ctcs,|d lD4D023
PRIOR LICENSUR"E
Has the owner or operator ofthe proposed establishment ever held a body art
!q@[iq license or permit?
ease lisI the information below. Attach additional pages if necessary.
$aes
nNo
Status (Active/Expired/Suspended)S unlcl ty Lic./C ./Reg. #
Statenr,Iunicipdity Lic./Cert./Reg. #
Has the owner or operator ofthe proposed establishment ever held a body art
9g@! license or permit?
If yes, please list the information below. Attach additional pages if necessary.
Status (Active/Expired/Suspended)
E Yes
trNo
State/I,Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Stateltr,funicipality 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
EMPLOYEE INFORMATION
Please list and all B Art Technicians attoo,erct nlice
Type of Body Art
Performed
Employee Name
2
Cftated I D412023
Requirements for Body Art Establishmeut Permit
Submit the following to complete your application:
tr A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
! Detailed floor and operation plans of proposed body art establishment (new applicants only)
n A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
! First Aid and CPR certifications
! Medical Waste Removal Confiact
! Bloodborne Pathogen Training
tr Aftercare information and instructions
I understsnd 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 witt 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 under"stand 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 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.
n
Full Name o Applicant
L
Da
It is your responsibility to renew your permit at the end of each calendar year.
3
atu
Cteatcd ln4n023
Applicant Statement of Consent