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Home My WebLink AboutEllen KorbelikTHE COMMONWEALTH OF MASSACHUSETTS TOWNOFYARMOUTH BOARD OF HEALTH PERMIT NUMBER: #24-018 FEE: S55.00/ Technician This is to Certi!that Ellen Korbelik 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 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts 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 bythe Board ofHealth, and expires December 31, 2024 unless sooner revoked. lanuary 1,2024, BOARD OF HEALTH:Hillnrd Boskcv, M.D., Clnirmnn Mnru Crais, Vice Chnirman Clmrles Hohi,av, derkEic Weston Laurance Veneziq DVM (date) James G. G Di th TOWN OF YARMOUTH l l 4ft808 C& SOUTH YARMOUTH, MASSACHUSETTS 02661'2445 1 Telephooe (508) 39V2211, *" 1241 FEB 0b 2024 Fa:r(50E)760-3472 HEALTH neP t Board of Health Health Division IVoe of Aoollcedon ONew pRcnewal ApplicarionFee(s):$f60/Frcility $S5/Technicien $Ss/Apprcntice Type(s)ofBodyArr DTattooFacility /fanootectnician DApprentice n Piercing Facility tr Piercing Tecbnician ESTABLISIIMENT INFORMATION q8 0ut< {8s B Name & (? ty State Typc of owncnhip: tr Sole hoprietor tr Corporation n Parhership If establishment is owned by a corporatior; partnership, or other combination of individuals, please attach tho name, title, tax ID#, and home address of all owners. Ectablbhment Owner's / Technicianc NsBe: First Last Middle Initial I Tax ID # (esta only) r rad L0-d,lcfricsrn Email Address 1 Phone b-2 qD Cr!,d lD4D023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art @[igi4 license or permit? list the information below.ttach additional s if necessary.a D4es DNo Status (Active/Expired/Suspended)ta ity Lic./Cert./Reg. # State/Municipality Lic./Cert./Reg. # Has the owner or operator ofthe proposed establishment ever held a body art 9g!g!!!q[3qg4! license or permit? Ifyes, please list the informotion below. Attach additional pages d necessary. Status (Active/Expired/Suspended) E Yes trNo State/\,lunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State,Municipality Lic./Cerr./Reg. #Status (Active,lExpired/Suspended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropdately ifpaid: Yes-No EMPLOYEE INFORMATION Please list and all Art Technicians attoo,erct enlicet Type of Body Art Performed Employee Name 2 Crcated l/24D0ai Requirements 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 applicants only) ! 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 Contact ! Bloodborne 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. f,W,!.n Slcnlu krw),^Vflicant l L Da It is your responsibility to renew your permit at the end ofeach calendar year. L4 3 C..det I D4D023 I hereby certif, 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.