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HomeMy WebLinkAboutChristian EliasTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF IIEALTH FEE: S55.00/ Technician This is to Certifu that Christian Elias 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 5l , 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 by the Board of Health, and expires December 31, 2024 unless sooner revoked. Jantarv 1,2024, BOARD OF HEALTH Hillard Boslceu, M.D., Choirman Maru Crais, ViceClwirmnn Chnrles Holtbnv, Gerk Eic Weston Laurance Venezia, DVM (date) James G.ner I Icalth PERMIT NUMBER:# 24-026 TOWN OF YARMOUTH I 146 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 02664.2M51 Telephone (50E) 398-2231, ext. 1241 Fax (50E) 760-3472 Board of Health Health Division Tvoe of Aoolication pNew f .(enewal AppiicuionFee(s):$160/Facility $ss/Technician $S5/Apprentice ,d fattao Technician tr Apprentice tr Piercing Technician Type(s) ofBody ArL tr Tattoo Facility I Piercing Facility ESTABLISHMENT INFORMATION s L/rt 0ul<l8 Name & ty State Type of ownenhip: D Sole Proprietor tr Corporation tr Partnership If e$abliqhment is orrmed by a corpordion, partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all oune$. Establishmelt Owrerns / Techtrlcians Ntme: Cl,<tsT/'nN Eues .-'- First Last Middle Initial 2 7 2n Date of Gender TaxID#(establishment7Lf/ ES4U AENQ/I/S Legal Mailing Address {oilN's Ts/nuo 5L ;a /5d7233 City 7 State zip ?o/'7r/-/4zo ch ri s/t'a ndt a s does /a lfus a .@t\ Email Address 1 Phone Number Cteabd lD4nA3 Lil vlrurnov+h t\A A.07b+1 PRIOR t-ICENSURE Has the owner or operator ofthe proposed establishment ever held a body art technician license or permit? Ifyes, please list the information below. Attach additional pages ifnecessary. E Yes trNo StateiMunicipality Lic./Cert./Reg. #Status (Active/Expired/S ed)s.c # rF- oar6 State/lvlunicipality Lic.lCert o*Status (Active/Expi Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please list the informalion belou,. Attach additional pages ifnecessary. E Yes !No State/Municipality 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 if paid: Yes_No EMPLOYEtr INFORMATION Please list and all Art Technicians tctttoo,lerct nticect Employee Name Type of Body Art Performed Z crcat d 1 /24n423 ! ! ! ! ! n ! tr ! Requirements for Body Art Establishment 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 lo) Detailed floor and operation plans ofproposed body art establishment (new appliconts only) A copy of Blood Exposure Control Plan Proof of liability insurance / Workman's Comp. Insurance Client application and consent forms First Aid and CPR certifications Medical Waste Removal Contract Bloodborne Pathogen Training Aftercare information and instructions Applicant Statement of Consent 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 bf 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. Full Name of Applicant 2pa Date It is your responsibility to renew your permit at the end of each calendar year. 3 I hereby certify, 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. tlCn(isrrnu flJfrs Crcated 't24D023 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.