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HomeMy WebLinkAboutDaniel LapcheskeTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YAR]I{OUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certifu that at Daniel L esk DIIt MilkS 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 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 3l . 2024 unless sooner revoked. Hillard Boskett, M.D ., Chairmon Maru Crais. Vice Chnirmnn Charles Holzrtaa, dirkEic Weston Laurnnce Venezia, DVM lantaw l. 2024.BOARD OF HEALTH: (date) James G. G ner ealth PERMIT NUMBER:#24-024 TOWN OF YARMOUTH Board of Health \t I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-2M51 Telephone (50E) 398-2231, ext. 1241 Fax (508) 760-3472 Health Division Tvne of Aoolication New 0- .Gnewal Applicuion Fee(s): $160 i Facility $55 / Technician $55 / Apprentic.ep Type(s) ofBody Aft tr Tanoo Facility I Piercing Facility ESTABLISHMENT INFON.MATION /TattooTechnician tr Apprentice D Piercing Tecbnician s 00IU 0ul<{8 Name & (p ty Stat€ Type of ownerohlp: tr Sole Proprietor tr Corporation tr Partnership If eqtatrlishment is oumed by a corporatio& partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all owne$. Establishment Owner's / Technicians Name:TfrairL LnPClEslE First Date Le City c7 Last Gender lil Tax ID ishment 5c@3 zip ( 7/o //D PlUr A AlKEN /can State 5/5- 357'?ots Email 1 Phone Number Address Crcsted 124201 4 Middle Initial PRIOR I,ICENST]RE Has the owner or operator ofthe proposed establishment ever held a body art !q[i9i4 license or permit? Ifyes, please list the information below. Attach additionol pages ifnecessary. ! Yes !No State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/S ended uspended) I Yes trNo )faui # Tnr-- /30 State/lvlunicipality Lic./Cert./Reg. #Status (Acti Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please list the information belou,. Altach additional pages ifnecessary. State,Municipality Lic./Cert./Reg. #Status (ActivelExpired/Suspended) State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth taxes and Iiens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: Yes_ No EMPLOYEE INFORMATION Please list and s ct all B Art Technicians attoo,lercln enlice Type of Body Art Performed Employee Name 2 Crealed 124f4'1- Requirements for Body Art Establishment Permit Submit the following to complete your application: n A copy ofowner's valid identification card with picture (state-issued license, passport, or military-issued ro) Detailed floor and operation plans of proposed body art establishment (npr{ applicants only) A copy ofBlood Exposure Control Plan Proof of liability insurance / Workman's Comp. Insurance Client application and consent forms First Aid and CPR certifications Medkpl Waste Removal Contract Bloodbome Pathogen Training 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 Iicensed Body Art Establishment Owner/Operator by those regulations. I also agree to comply with all of the regulation requirements specified in the Yarmouth Board bf Health Body Art Regulations while practicing in the Town of Yarmouth. I hereby ceftiry, 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. \ r\\ D ! ! D n D ! -DfraDL flEs e of Applicant Date It is your responsibility to renew your pennit at the end ofeach calendar year. 3 re Crcated lD4/2023 I further understand that it is my responsibility to ensure thrt 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.