HomeMy WebLinkAboutBenjamin ButtsTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-Ol9 FEE: $55.00/ Technician
This is to Ce(ifo that Beniamin Butts
at S It 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 5 I . ofthe General Laws. ani amendments theretoi and is subject to the provisions ofihe 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.
January I ,2024, BOARDOFHEALTH:Hillard Boskev, M.D., Chairmnn
Mara Crnis. Vice Chairmnn Charles
Holioav, Cferk
Eic Weston
Laurance Venezia, DVM
(date)
James G.
Director of Health
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSEfiS 026&.24451. Telephone (508) 39E-2231, ext. l24l
Fax (50E) 760-3472
Board of
Health
Health
Division
Tvoe ofaoolicetion HEALTI-r i'i:-P I
oNew flRenewal ApplicationFee(s):$160/Facility $55/Technicirn $55/Apprentice
Type(s)ofBodyArt DTattooFacility r.dtattootechnician trApprtntice
E Piercing Facility tr Piercing Technician
ESTABLISIIMENT INtrORMATTON
Soltu;rL 0uft18
-rsiEssNamtE
Lb
ity State zip
Type of owncnhip: tr Sole Proprietor tr Corporation D Partn€rship
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach the narne, title, tax ID#, and home address of all owners.
Erteblbhmcnt Owner's / Technicianr Name:
N
First Last Middle Initial
irth Tax ID enly)
a llu)
ling
rte/1 z/l
State p
bu
Email Address
1
Number
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C'tlfid 1t24D023
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
technician license or permit?
If yes,ease lt the information be tional pages if necessary.
afes
trNo
low. Attach addileLVgL +r
Status (Active/Expired/Suspended)unlcipality Lic./Cert./Reg. #
StateMunicipality Lic.iCert./Reg. #Status (ActiveiExpired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
If yes, please list the information below. Attach additional pages if necessary.
E Yes
trNo
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #Starus (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
EMPI,OYEE INFORMATION
Please list and all Art Technicians attoo,lercl nliceclI
Type ofBody Art
Performed
Employee Name
2
Cft^ed lD4D023
!
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
A copy ofowner's valid identihcation card with picture
(state-issued license, passporl, or military-issued to)
Detailed floor and operation plans of proposed body a( establishment (new applicants only)
A copy of Blood Exposure Control Plan
Proof of liability insurance / Workman's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Medical Waste Removal Contract
Bloodbome Pathogen Training
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.
fun Afis
n
n
n
n
n
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F e of Applicant
It is your responsibility to renew your permit at the end ofeach calendar year.
3
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ate
Crcated lD4n023