HomeMy WebLinkAboutCharles OttoTHE COMMONWEALTH OF MASSACHU ETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-025 FEE: $55.00/ Tcchnician
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issucd in conformily with thc aurhonty granted to the Board of Healrh. by Chaprcr 140,
Sections 5 I , ofthe Gcncral Laws. and amcndmcnts therelol and is subiect to the provisions ofihc Laws olthcCommonwcallh of Massachusctts rclating lhcreto. and upon such tcrins and conditions, and to thc rulcs andregulations in rcgald_ to-th-ccarrying on oithe occupation so licensed as adopted by the Board oI Hcalth. antlcxpires Decembcr 31. 2024 unlcss sooncr rcvoked
Janu 20:.1 BOARD OF HEALTH Hillnrd Bosketl, M.D., Clmirnmn
Moru Crnip, Vice Choinrnn Clnrles
Holzbav, C'lerk
Eric Weston
Laurance Venezia, DVM
(datc)
Jamcs G rdiner
Hcalth
This is to Certily that Charles Otto
.,<
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSEfiS 026&'24451
Telephone (508) 398-2231' ext' 1241
Fax (50E) 760'3472
Board of
Health
Health
Division
Tvoe of Aoolicatior
pNew O- .(enewal
I
Application Fee(s): $160 / Facility $55 / Technicirn $55 / Apprcntiee
Type(s)ofBodyArt DTattooFacitity
! Piercing FacilitY
ESTABLISHMENT INFORMATION
lfattoofecbnician B Apprelrtice
tr Piercing Technician
..
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/-/ AIU 0u/< {8
Name&
(?
ty State
First Last Middle Initial
2o g
B ax ID ishment v)
Tlpe of owuerthip: tr Sole Proprietor tr Corporation D Partnership
If e$abli shment is orrmed by a corporation, partrership, or other combination of individuals' please
attach thc name, title, tax ID#, and home address of all owners'
Establishment Owner's / Techniciang Name:
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5S cn zip
tAazrfur/oo
StateCity
/(- g{/'3VoO ditto @ )/,
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Number
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PRIOR LICENST]RE
Has the owner or operator ofthe proposed establishment ever held a body art
!g@19i9 license or permit?
If ve ease /rst the information below. Attach additional pages i.fnecessdrv.s
S unicipality Lic./Cert./Reg. #Status (Active/Exp
o Y3s-
'firt;
State/Municipality Lic./Cert.iReg. #
Has the owner or operator of the proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information belou,. Attach additional pages ifnecessary.
Status (Active/Expired/Suspended)
Statel-lvlunicipality Lic./Cert./Reg. #Status (Active/Expired./Suspended)
State/lvlunicipality Lic./Cert./Reg. #Status (ActivelExpired/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
Plesse list and ct all Art Technicians Itoo,letc nlice.l
Type ofBody Art
Performed
Employee Name
2
I Yes
trNo
crcargd I n4n023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued lo)
! Detailed floor and operation plans of proposed body art establishment (new applietnts only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
D Client application and consent forms
! First Aid and CPR certifications
! Medical 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 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 Heatth 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 certiff, under penalties and pains of perjury, that to the best of my knowledge the
information provided on this application is complete end accurate and in no way misrepresented.
Cmzzs Oro
licant
Date
It is your responsibility to renew your permit rt the end ofeach calendar year.
3
Signa
Cr.ated I D412023
Full Name of
t