HomeMy WebLinkAboutWilliam RochaTHE COMMONWEALTH OF MASSACHUSETTS
TOwl\ OF YARIUOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-021 FEE: $55.00/ Technician
This is to Certi& tlnt William Rocha
at Sr)lIt 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 of Massachusetts relating thereto, and upon such temrs 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 3l , 2024 unless sooner revoked.
Hillnrd Boskeu, M.D., Chnirmnn
Mara Crais, Vice Chnirmnn Charles
Holil,nv, Clerk
Eic Weston
Laurance Venezin, DVM
u I 2024 BOARD OF HEALTH:
(date)
James G
Director o ealth
T N OF YARMOUTH
Health
Division
Tvne of Aoolication
E New fl Renewal Appiication Fee(s): $150 / Facility $55 / Technician $55 / Apprentice
,d Tattoo Technician tr APPrentice
tr Piercing Technician
t4 0ut< 18
Type(s) ofBody Art: tr Tattoo Facility
! Piercing FacilitY
ESTABLISIIMENT INFORMATION
S
Name &
7
State zip
Typc of ownership: tr Sole Proprietor tr Corporation tr Partnaship
If establishment is owned by a corporation, partnership, or other combination of individuals, please
attach tho name, title, tax ID#, and home address of all owners.
Establbhment Owner's / Technicians Name:
First Last Middle Initial
0
v 1
B Tax ID
tate
04
+-a
1
Phone Number
0 q[2 co
Credrd lD4D023
Board of
Health
I I46ILQUTE A&SOUfl{ YARMOUTH, MASSACHUSETTS 02654.2445I
I Lts I.l,'r I U lq Telephone (50S) 39&223 l, ext. 1241
Fax (508) 760-3472
HEALTH LlEP''J
I
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
technicien license or permit?
list he informatio n Attach addrtional pages if necessary.
Fes
nNo
Status (Active/Expired/S uspended)State,Atlunici ty Lic./Cert./Reg. #
State/Ivlunicipality Lic./Cert./Reg. #Status (ActiveiExpired/Suspended)
Hss the owner or operator ofthe proposed establishment ever held a body art ! Yes
estab ent license or permit?!No
If yes, please list the information below. Attach additional pages dnecessary'
State/Municipality Lic./Cert./Reg. #Status (ActivelExpired/Suspended)
State,&,Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits'
Please check appropriately ifpard: Yes No
EMPLOYEE INFORMATION
Please lisl and s all Art Technicians ttoo,erct enlice
Type ofBody Art
Performed
Employee Name
2
Ct dd 1124D023
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 Bosrd of Health will be mailed to the address indicated on this
application.
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 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.
w\lliam 8o ila
icant
ate
It is your responsibility to renew your permit at the end ofeach calendar year.
3
ature
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 Confol Plan
E Proof of liability insurance / Workman's Comp. Insurance
tr Client application and consent forms
n First Aid and CPR certifications
E Medical Waste Removal Contract
! Bloodbome Pathogen Training
D Aftercare information and instructions
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.
Full
Crcarcd lD4D023