HomeMy WebLinkAboutAlex CitroneTHE CO ONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifo that Alex Citrone
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 authonty granted to the Board of Health. by Chapter 140,
Sections 51, ofthe Ceneral Laws, and amendments theretoiand is subject to the provisions ofihe Laixs ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations ir: regard to the carrying on oflhe occupation so licensed as adopted by the Board of Health. and
expires December 31, 2024 unless sooner revoked.
I 2024 BOARD OF HEALTH:Hillard Bosky, M.D., Chnirman
Maru Crais. Vice Chnirman Chnrles
Holzi,av, ClirkEic Weston
Lnurance Venezia, DVM
(date)
lo,,"-og*l--ffi/ Director o]fralth
PERMIT NUMBER:#24-020
TOWN OF YARMOUTH
I 146 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
Telephone (50E) 398-2231, ext. 1241
Fax (508) 760-3472
, ti.
Board of
Hcalth
Health
Division
Tvoe olAoolication
E New fl Renewal Application Fee(s): $160 i Facility $55 / Technician $55 / Apprentlce
,d Tattoo Technician tr APPrentice
u Piercing Technician
Type(s) ofBody Art tr Tanoo Facility
n Piercing FacilitY
ESTABLISHMENT INtrORMATION
S I
Buslness Name &
(?
ty State zip
Type of ownerrhip: tr Sole hoprieror tr Corporation n Partnership
If establistrment is owned by a corporation" partnership, or other combination of inrtividuals, please
attach the name, title, to< ID#, and home addrcss of all owners.
Ect$li.hnert Owner'r / Technicianr Name:
/)0
Last Middle Initial
0ut< 18
Date irth Tax ID #only)
r-)TX 7g+z
zipState
fa r
Email Address
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PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
!q@!gjg license or permit?
If yes,ease list the information be ow 4t tional Wges if necessary.
Fes!No
Status (Active/Expired/Suspended)Sta unicipality Lic./Cert./Reg. #
State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art E Yes
estab ent license or permit?nNo
If yes, please list the information below. Attach additional pages if necessary.
State,Municipality 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 renewll or issuance of your permits.
Please check appropriately ifpaid: Yes No
EMPLOYEE INFORMATION
Please list and s all Art Technicians tattoo,erc 0 ntice
Type ofBody Art
Performed
Employee Name
2
cfta,led I D4D023
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.
*l.ex C,rlnn e
Full Name of Applicant
te
It is your responsibility to renew your permit at the end of each calendar vear.
2
3
crcatcd 1D4t2()23
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 ro)
! Detailed floor and operation plans ofproposed body art establishment (new applicants only)
tr 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 Contract
! Bloodbome Pathogen Training
! Aftercare information and instructions
Applicsnt 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 wilt be mailed to the address indicated on this
applicetion.
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
Estabtishment 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 speci{ied in the Yarmouth Board of Health Body Art
Regulations.