HomeMy WebLinkAboutClaire HoangTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OP YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so licensed as adopted bythe Board of Health, and
expires December 31, 2024 unless sooner revoked.
Ausust 30. 2024.Hillard Boskcv, M.D., Chnirmnn
Mnnt Crais.Vice Clwirman Clnrles
Holi,nu, C'firk
E.ic Weston
Laurance Venezia, DVM
(date)
James G tner
ealth
PERMIT NUMBER: # 24-080
This is to Certifu that Claire Hoans
BOARD OF HEALTH:
TOWN OF YARMOUTH Boartl of
t{calth
I I45 ROUTE 2t, SOUTH YARMOUTH, MASSACHUSETTS 02664.24451
Telephone (50t) 39&2231,ert- 1241
Fax (50E) 76G,3472
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E N€lil F Renewal Applicatioa Fo{$: $160 / Frcilrty $55 / Techniciu $55 / Appratice
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n Pierchg Facility D Piercing Tec-hnicisn
ESTABIJSIIIMEI{T INFOB" TATK)N
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Name&
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Typc of omcnhb: B Sole Proprietor tr Corporaion n Partncrship
If establishent is ovmed by a corporation, pstnership, or other combirdion of individuals, plcase
attach the name, 6tlo, t8x ID#, md bome ad&ess of all owners.
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Last Middle Initial
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Legal Mailing Ad&e#
PRIOR LICENSI'RE
IIes the owtrer or operator of the proposed establishment ever held a body arrt
technician license or pemit?
If yes, please li* the information below. Aftach additional pages if necessary.
nNo
State,{r4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)r tt(,rl bL-ZZ-tr|y h+StateT@d$'- Lic./cert.lteg. +Status (Active/Expired/Suspended)
E Yes
trNo
Eas the owner or operrtor of the proposed establishment ever held a body art
estsblishment license or permit?
Ifyes, please lkt the information below. Arach additional pages ifnecessary.
Statefir,Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. # Status (Active/Expfued/Suspended)
Town of Yarmouth taxes rtrd liens must be paid prior to renewal or issuance of your permits.
Please check appropriately if paid; Yes No
EMPLOYEE INFORMATION
Please list and all Art Technicians erc tce
Type ofBody Art
Performed
2
Crcated 1D4n
Fes
Employee Name
Requirements for Body Art Esteblishment Pemit
Submit the following to complete your application:
D A copy ofowner's valid identification card with picture
(state-issued license, passpod, or military-issued ro)
D Detailed floor and operuion plans of proposed body art establislunenr (new applicent onty)
I Acopy ofBloodExposure Control Plan
I Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
D First Aid and CPR certifications
E Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftercare information and instuctions
Applicant Strtement of Consent
I uldergtand thrt this.pemit is vdid only in the Town of Yermouth and expircs at the end of
thc celcnder yeer in which it wec fuued. I rko utrderstrnd thst rny notice to be meiled to me by
the Town of Yarmouth Board of IIerIth will be mailed to the addres itrdicated on this
application.
I have neceived r c'opy of thc Yarmouth Boerd of Heelth Body Art Reguletions. I heve rerd
rnd urdoBtrnd the obligrtioN rtrd EquircmentE impoEed upon a licensGd Body Art
Estrblishment Owtrer/Operetor by those regulations. I also agree to comply with all of the
regulrtbn rcquirements spccified in the Yarmoutb Board of Health Body Art Regulations
while pncticing in the Town of Yrnmouth.
I frrrther undostrnd thrt it is ny responsibility to ensurt thrt irdividual Body Art Technicians
working in thir estrblbhment hrve a current valid Yarmouth Board of Health Body Art
Technician License and comply with dl epplirnblc heelth, safety, senilation, sterilization, and
work prectices rreguletions rs speciied ir the Yrrmouth Board of Heelth Body Art
Regulations.
Full Nene of Applieentdu#,w-t/zo/zli-DeG
It h your respomibility to renew your p€rmit et the end of each calendar yeer.
J
S@ature
cftded tD4n(
I hereby certify, under pcnrhies rnd prins of pcrjury, thet to the best of my knowledge the
infometion pnovided on thb epplicrtion is complete end accunte and in no way misrepresented.
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