HomeMy WebLinkAboutJames CrossTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YAR]T{OUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu James Cross
at SDiIt 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 5 I . ofiheGeneral Laws, and amendments therCto, and is subject to the provisions ofihe Laws ofthe
Commonwealth of Massachusetts relating lhereto, and upon such terms and coirditions, and to the rules and
regulations in regard to thecarrying on ofthe occupation so licensed as adopted bythe Board ofHealth, and
expires December 3l, 2024 unless sooner revoked
January 1.2024. BOARD OF HEALTH:Hillord Boskeu, M.D., Chnirmnn
l1.4ary Crn1g, Vice Chnirman Clnrles
Holrunu, Llerk
EicWeston
Laurance Venezia, DVM
(date)
James G
Directoro rh
PERMIT NUMBER: # 24-016
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.24451.,. Telephone (508) 398'2231, ext. 1241' Fax (508) 760-3472
Board of
Health
Health
Division
IVoe ofAoolhedon HEALTH DEIrI
ONew flRenewal ApplicationFee(s):$160/Frcility 355/Technicirn $55/Apprentice
Type(s) ofBody Art tr Tattoo Facility
n Piercing FacilitY
TSTABLISIIMENT INRORMATION
S 0ut< 18
B Name &
ty State zip
12
irst Middle Initial
Tax ID
f tarootecbnicim u Apprentice
tr Piercing Tecbnician
L
(
H t
+0 t(Ft
zip
0Ll I (Ln1
Email
1
Number
r
Cr!{ed lD4n023
Type of ownerrhip: D Sole hopri*or tr Corporation tr Partnership
If esablishment is owned by a corporatioq partnership, or other combination of individuals, please
atach tho name, title, ta:< ID#, and home address of all owners.
Ect blbhmcnt Owner'a / Technicianr Neme:
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
lgg@igig license or permit?
list the i tion below. Attach additionalpages if necessary.
@""
!No
Status (Acti ired/Suspended)S unlcipality Lic./Cert./Reg. #
State/\4unicipality Lic./Cert./Reg. #
Has the owner or operator of the proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information below. Auach additional pages if necessary.
Status (Active/Expired/Suspended)
E Yes
trNo
State/lvfunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Ivlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
No
EMPI,OYEE INFORMATION
Please list and s cl all Art Technicians lattoo,erc I a ntice
Type ofBody Art
Performed
Employee Name
ct
^cd
lD4D023
Please check appropriately ifpaid: Yes-
2
' Requiremenb 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 of proposed body art establishment (new applicanh only)
E A copy ofBlood Exposure Control Plan
D Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
n First Aid and CPR certifications
I Medical Waste Removal Contract
! Bloodbome Pathogen Training
E 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 certify, 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 plicant
It is your responsibility to renew your permit at the end of each calendar year.
3
ignature
Ct.^.d I D4/2023
ntq<n+-
Datel