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Home My WebLink AboutAaron MurrayJames C. G Direct THE COMMONWEALTH OF MASSACHUSETTS TOWN OFYARMOUTH BOARD OF IIEALTH PERMIT NUMBER: #24-027 FEE: $55.00/ Technician This is to Certifo that Aaron Murray 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 by the Board of Health, and expires December 31, 2024 unless sooner revoked. January 1,2024, BOARD OF HEALTH (date) Hillnrd Bosl<ev, M.D., Chnirnnn Maru Crais, Vice Chairmnn Charles Holil'av, Clerk Eic Weston Laurance Venezin, DVM ealth TOWN OF YARMOUTH I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02654.2445I Telephone (508) 39E-2231, ext. l24l Fax (50E) 760-3472 Board of Health Health Division Tvne of Aoolication New O- .(enewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprenticep Type(s) of Body Art: tr Tattoo Facility n Piercing Facility ESTABLISHMENT INFORMATION f fannoTechnician tr Apprentice tr Piercing Technician s L/fr 0ut< {8 Name & Lb ty State zip Type ofownenhlp: tr Sole Proprietor tr Corporation tr Partnership If establishmeilis owned by a corporatio& partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all o1ryne$. Establishment Owner's / Technicians Name:frnruil [ilqw s Middle InitialFirstLastolatlqS lilF"f Gender Tax ID only) 3e'fr-S7 337 /, City State 7ab-17 v-/2a7 Email Address 1 Phone Number creatd lD4D023 PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art I Yes technician license or permit? n Nn ,please list the in ifrmcttiobel. Attach additional aryne cess /5a Starus (Active/Expired/S + tate/Ir4unicipality Li ert./Reg. #) StateiMunicipality Lic./Cer.iReg. #Status (Active/Expired/Suspended) I Yes trNo Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? Ifyes, please list the information below. Attach additional pages ifnecessary. State/Municipality Lic./Cert./Reg. #Status (Active/Expired./Suspended) State/Municipality Lic./Cert./Reg. # Status (ActiveiExpired/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 Please lisl and s cl all Bo Art Technicians too,terctn a nlice Type ofBody Art Performed Employee Name Crc ted 1D4no)1 EMPLOYEE INFORMATION I 2 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) ! Detailed floor and operation plans of proposed body art establishment (new applieants only) n A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance D Client application and consent forms D First Aid and CPR certifications n 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 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 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. fiaran Srmt fluznn Full me of Applicant b L ?o) Date It is your responsibility to renew your permit at the end of each calendar year. 3 S ture Crcated lD4l202i 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.