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Home My WebLink AboutElizabeth PotterTHE MNI NWEALTH OF MASSACHUSETTS TOWI\ OFYARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-079 FEE: $55.00/ Technician This is to Certifo that EI P at Soilt 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 5l , ofthe General Laws, and amendments thereto, and is subject to the provisions oflhe 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 3l , 2024 unless sooner revoked. Ausust 30. 2024.BOARD OF HEALTH:Hillnrd Boskev, M.D., Chnirman Mnru Crais.Vice Chnirrunn Clnrles Hold,av, Cferk Enc Weston Laurance Venezia, DVM (date) <L,-* (aJ-t-7 r,-;eaN;;' Direct6r+F(ealth TOW N OF YARMOUTH I146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 026il-24451 Telephone (50E) 39E 2231, ext' 1241 Fax (508) 760'3472 Board of Health Health Division Tvoe of Aoolication p New O- .(enewal Application Fee(s): $160 i Fecility $55 / Technician $55 / Apprcnticc I f fattoo fecfniciar tr APPrentice tr Piercing Technician Type(s) ofBody Art DTattoo Facility D Piercing FacilitY ESTABLTSHMENT INFORMATION CU B Name & I State 0Uft ,28 Lb zip D PartnershiPType of owneruhip: tr Sole Proprietor tr Corporation If establishment is owned by a corporatiog partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all owners' Est&blbhnent Owner's / TechDicisns Nrme: %izaht*h First Last Middle Initial q Z of Tax ID # L Address r I lav City State 5 zip -/t. .L Number 3-b /n ,f0rt CrcrEd I D4D023 Z PRIOR LICENSURE Has the owner or operator of the proposed establishment ever held a body art !q$!gi4 license or permit? If yes, please list the information below. Attach additional pages if necessary. ftrNo w State,Municipality l,ic./Cert./Reg. # q Status (Active/Expired/Suspended) State/M cipality Lic./Cert./Reg. # Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please list the information belov,. Attach additional pages ifnecessary. Status (ActiveiExpired/Suspended) D Yes trNo State/Tvlunicipality Lic.iCert./Reg. #Status (Active/Expired/Suspended) State/)vlunicipality 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 if paid: Yes-No EMPLOYEE INFORMATlON Pleose list and all Art Technicians lattoo,erctn a nticeci Type ofBody Art Performed Employee Name 2 Crealed l/24D023 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 thal 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 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. ELiz 14^ ?ol<r Full Name of Applicant 2l It is your responsibility to renew your permit at the end ofeach calendar year' 3 t teSignature Cteated 1/24D023 Requirements for Body Art Esteblishment Permit Submit the following to complete your application: ! A copy of owner's valid identification card with picture (state-issued license, passport, or military-issued Io) tr 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 E Client application and consent forms l tr First Aid and CPR certifications ! Medical Waste Re.rnoval Contract ! Bloodbome Pathogen Training f] Aftercare information and instructions E NWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certili that Elizabeth Potter 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 ganted to the Board of Health, by Chapter 140, Sections 51, oftheGeneral Laws, ani amendments thereto]and is subject to the provisions ofihe Lair'rs ofthe Commonwealth ofMassachusetts relating thereto, and upon such teins and coirditions, 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 Aueust 30, 2024,BOARD OF HEALTH:Hillard Boskcv, M.D., Chairman Marv Crais. V ice Chnirman Clnrles Holionv, Clirk Eic Weston Laurance Venezia, DVM 4*-(a^^/-- (date) / lu-.. c. cbi"o Direct6+sfllealth PERMIT NUMBER: # 24-079 TOWN OF YARMOUTH I 146 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 026il-24451 Telephone (50E) 39E-2231' ext' 1241 Fax (508) 760'3a72 Board of HeaIt[ Health Division Tvoe of Aoolicetion pNew g'lenewal I Application Fee(s): $150 i Fecility $55 / Technician $55 / Apprtnticc Type(s) ofBody Art DTattoo Facility a Piercing FacilitY ESTABLTSHMENT INFORMATION f ramore*nlcian D APPrentic'e tr Piercing Technician s q8 0uft{8 Name & (, ty State p Type of ownenhip: tr Sole Propriaor tr Corporation tr Partnership If establishment is owned by a corpordioq partnership, or other combination of individuals, please attach the name, title, tax ID#, and home addrcss of all owners' Estrblishment Owner's / Techdcianr Nsme: fhz Last Gender Middle InitialFirst q Z rZ ofB Tax ID (establ I u City zip 0 ./ State 5 \ Phone Number 3-b ln Cnar(d lD4n023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art !g[!gig license or permit? If yes, please list the information below. Attach additional pages i.f necessary. r\"trNo w State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State,M cipaliry Lic./Cert./Reg. # Has the owner or operator ofthe proposed establishment ever held a body art estab hment license or permit? Ifyes, please list the information belov'' Attach addilional pages ifnecessary. Status (Active/Expired/Suspended) I Yes trNo State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State/lr4unicipality Lic./Cert./Reg. #Status (Active/Expired/Sus pended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: Yes--No E MPLOYEE INFORM ATION Please list and s.all B Art Technicians loo,erctn entice Type ofBody Art Performed 2 C',eat<n I D4nA23 Employee Name 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) tr Detail,ed floor and operation plans of proposed body art establishment (new applicants only) tr A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance D Client application and consent forms I tr First Aid and CPR certifications ! Medical Waste Removal Contr@t ! Bloodbome Pathogen Training n 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 certiS, 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. ELiza47,14a 70+Rr Full Name of Applicant 2a It is your responsibility to renew your permit at the end ofeach calendar year. 3 I teSignature Crcat d ID412023