HomeMy WebLinkAboutTemola AddleyTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu thrt Temola Addlev
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 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.
Hillard Boskeu, M.D., Chnirman
Maru Crnis. V ice Clnirmnn Chnrles
Holi,nv, dirkEic Neston
Lnurance Venezia, DVM
January 1.2024.BOARD OF HEALTH:
(date)
-/o^,-*'\.-,A)James e Glrdiner
Director of Health
PERMIT NUMBER: # 24-015
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 0266/.24451
REC * rV filephone (508) 39E-223 I, ext 1241
Fax (50E) 760'3472
I'[B irtr 2024
Board of
Health
Health
Division
TVoe ofAoollcrdon HEALTH DEPT
o New fl Rcnewal Application Fee(s): 0160 i Facitry $55 / Technictrn $55 / Apprentlc*
Type(s)ofBodyArc DTattooFacility /tattoofecUician DApprentice
E Piercing Facility tr Piercing Technician
ESTABLISHMENT NTOR.MATION
S 0uft18
Name &
b
State p
Type of ownenhip: tr Sole Proprietor tr Corporation tr Partnership
If establishment is owned by a corporatiorl partnership, or other combination of individuals, please
attach tho name, title, tax IB, and home address of all owne$.
Egtrblishment Owner's / Technicianr Name:
irst Last Middle Initial
ax rD#(
7
N 204
State zip
Email
1
Phone
ur*
Ct M ID4DW
b
PRIOR LICENSURE
Has the owner or operator ofthe proposed $tablishment ever held a body art
!99,!4!9fu license or permit?
Ifyes, please list the information below. Attach additional pages ifnecessary.
! Yes
DNo
State/Municipality Lic.iCert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
If yes, please list the information below. Attoch additional pages if necessary.
Status (Active/Expired/Suspended)
E Yes
trNo
StateA,Iunicipality 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 ifpard: Yes No
EMPLOYEE INFORMATION
Please list and s all Art Technicians laltoo,erct nlice
Type ofBody Art
Performed
Employee Name
Z
creeted I D4n023
Requirements for Body Art Establishment 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 ro)
tr Detailed floor and operation plans ofproposed body art establishment (new applicants only)
I A copy ofBlood Exposure Control Plan
D Proof of liability insurance / Workman's Comp. Insurance
U Client application and consent forms
! First Aid and CPR certifications
E Medical Waste Removal Confiact
! Bloodbome Pathogen Training
E Aftercare information and instructions
Applicanl 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 bf 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 applicrble 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.
ll Name of Applicant
(,
te
It is your responsibility to renew your permit at the end ofeach calendar year.
3
ature
Cftd..d I D4D023