HomeMy WebLinkAboutMatthew StewartTHE COMMONWEALT A HU E
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certi!fh^f Nrleflh Stewart
at Snilt 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 5 I , ofthe General Laws. and amendments thereto. and is subject to the provisions ofihe 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 by the Board ofHealth, and
expires December 31, 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:
(dare)
Hillard Boskty, M.D., Chnirman
l/laJy Crn1g, Vice Chairman Clnrles
t70l7t ou, clerk
Eic Weston
Laurnnce Venezia, DVM
James G.
Director o
PERMIT NUMBER: #24-022
TOWN OF YARMOUTH
I 146 ROUTE 28. SQUTH YARMOUTH, MASSACHUSETTS 02654.2445I
ttB !'l lt6fuphone (sos) 39v223t, qL 1241
Fax (508) 760-3472
HEALTH iJLi'"
Bosrd of
Heatth
Health
Division
IVne of Aonlication
tNew flRenewal AprplicationFee(s):s160/Facility $55/Technicirrn $55/Apprentlce
Type(s) of Body Are tr Tattoo Facility / famo tecUician tr Apprentice
tr Piercing Facility ! Piercing Tecbnician
ESTAELISIIMENT INFOR,MATION
S 0uft18
B Name &
7b
ty State
Type of owncnhip: tr Sole Proprietor tr Corporation tr Partnership
If establishment is oumed by a corporation, partnership, or other combination of individuals, please
attach tho name, title, tax lD#, and home address of all owners.
Estrbtbhmetrt Owner's / Technicianr Name:t
First Last Middle Initial
Birth Gender Tax ID #
L3W nArrYl
A a32J+ - qqF
zip
\Ll-gbq-azq a,uforont
Email Address
a-.t'/. carn
t
Number
0
Cft,rn ln4D023
PRIOR LICENSUREff ". oi operetor of the proposed establishment ever held a body art )@es
@@!gig license or permit? trNo
tthei
Sta unlc ipality Lic./Cert./Reg. #
if necessary.ft
Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art I Yes
establishment license or permit? tr No
If yes, pleose list the information below. Attach odditional pages if necessary.
State/Mmicipality 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 renewal or issuance of your permits.
Please check appropriately ifpaid: Yes-.=- No
EMPLOYEE INFORMATION
Please lisl and s all Art Technicians laltoo ercln ntice
Type ofBody Art
Performed
Employee Name
2
Cred,.d I D4D023
below. Attach additional
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 ofproposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
I Client application and consent forms
n First Aid and CPR certifications
E Medical Waste Removal Contract
n Bloodbome Pathogen Training
f] Aftercare information and insfiuctions
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 Heaith 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 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.
{\u*fu*o dlu,rtalf
Full Name of A licant
Date
It is your responsibility to renew your permit at the end of each calendar year.
3
Ct.did 1 D4/2023