HomeMy WebLinkAboutJason SmalleyTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-017 FEE: $55.00/ Technician
This is to Certifo tlnt Jason Smalley
at Spilt Milk
Hillarul Boskey, M.D., Clmirman
Mara Crais. Vice Chairmnn Chnrles
Holzi,av, Clirk
Eic Weston
Laurance Venezia, DVM
Jaruary 1,2024. BOARD OF HEALTH:
(date)
*L^"^S-.-l--Zr-..G^G;.II*./ Director o\I6atth
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so licensedas adopted by the Board ofHealth, and
expires December 31,2024 unless sooner revoked.
TOWN OF YARMOUTH
l r4,ff59ft l$tourrt YARMourH, MAssAcHUSETTs 02561-24451
.^^ Telephone (50E) 39&2231, ext l24l
FtB ild 2024 Fax(56t)760-34?2
HE?LTH i]T]P'
Board of
Health
Healtr
Division
IVoe of Aoollcedon
oNew flRenewal ApplicationFee(s):$150/Faciltty $55/Techniciln $55/Apprcntice
Type(s)ofBodyArt trTanooFacility y'famotectrnician trApprentice
tr Piercing Facility tr Piercing Tecfutician
ESTABLISIIMEN? INRORMATIOI
Snirt ltri t(q8 0uft{8
arsiile"s Nsrni'&
It-
ty State zip
Type of owncrship: tr Sole Proprietor tr Corporation n Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the name, title, tax ID#, and home ad&ess of all owners.
Establlrhment Owner's / Tcchnicirnr Name:
First Last Middle Initial
a
Date Tax ID (establ enly)
Le
s003 0
ty State zip
q
Email
a'I
C t r>-t
L
Number
C..M lt24l2$B
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
!g[jg!4 license or permit?
e lisl lhe in ion below. Attach s,necessary.
1
7I"'trNo
Status (Active/Expired/Suspended)S unlcipality Lic./Cert./Reg. #
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art n Yes
establishnrellt license or permit?trNo
If yes, please list the information below. Attach additional pages if necessary.
State^,Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/lr4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmouth taxes and tiens must be paid prior to renewal or issuance of your permits'
Please check appropriately ifpaid: Yes-No
EMPLOYEE INFORMATION
Please list and cl all Art Technicians oo,terctn ntices
Type ofBody Aa
Performed
Employee Name
?
Creded I D412023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy of owner's valid identification card with picture
(state-issued license, passport, or military-issued to)
tr Detailed floor and operation plans of proposed body art establishment (new applicant! only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
tr Client application and consent forms
n First Aid and CPR certifications
tr Medical Waste Removal Confiact
! Bloodbome Pathogen Training
n 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 Heatth 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 Yarmoutb Board of Health Body Art
Rcgulations.
I hereby ceftiry, 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.
L
Full Name of Applicant
te
It is your responsibility to renew your permit at the end ofeach calendar year.
Z
3
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Created 1 D4D023