HomeMy WebLinkAboutGerald FelicianoJames G
Di
THE COMM NWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu that Gerald Feliciano
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 5 I , ofthe General Laws, and amendments theretol and is subiecl to the provisions ofihe Laws oftheCommonwealth ofMassachusetts relating therelo, and upon such terins and coirditions, and to the rules andregulations in regar_d_ to-th-ecarrying on ofthe occupation so licensed as adopted by the Board of Health, andexpires December 31, 2024 unless sooner revoked
lanuary 1,2024. BOARD OF HEALTH:Hillard Bosl<ey, M.D., Clnirmnn
Maru Crois, Vice Chairman Chnrles
Holiunv, Clirk
Eic Weston
Laurance Venezia, DVM
(date)
lner
ealth
PERMIT NUMBEP.: #24-028
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 026&'24451
Telephone (50E) 39E 2231, ext' 1241
Fax (508) 760-3472
Board of
Health
Healtlr
Division
Tvre of Aoolicetion
p New O'lenewal
Type(s)ofBodyArt: DTanooFacility
D Piercing FacilitY
FSTA BLISHMENT INF1ORMATION
etJ
Nanre &
Last
Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice
,,d fattoo fecUician o APPrentice
tr Piercing Technician
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State
Tax ID # (e
tate
0 ult
7b
zip
n PartnershiP
Middle Initial
only)
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itv
Type of owncnhlp: tr Sole Proprietor tr Corporation
If estahlishment is ouored by a corporation, parhership, or other combination of individuals' please
attach tlro name, title, tax ID#, and home address of all owners'
LD FflJUftlUO
egal
Date B
City
ufo/rl 9T
'r/
6 /b' 7t{'7 727
/222
zip
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Number Address
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Establbhnent Owner's / Technicianr Name:
J'JN 2" '
L
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification card with pictue
(state-issued license, passport, or military-issued to)
n Detailed floor and operation plans of proposed body afl establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
D 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 that any notice to be mailed to me by
the Town of iarmouth 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 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 Att
Regulations.
I hereby certify, under penalties and pains of perjury, that to the best of my knowledge the
information piovided on this application is complete and accurste and in no way misrepresented.
6r,<nt> Fil'anruo
Fult Name of A plicant
b 6 ..>
1.
Date
It is your responsibility to renew your permit at the end ofeach calendar year.
3
Signature
crcated I 124D023
PRIOR LICENSURE
Has the owner or operator of the proposed establishment ever held a body art
lglgigig license or permit?
Ifyes, please list the i4formation below. Atlach additional pages ifnecessary.
I Yes
trNo
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
ol tYcrrl /x,U- + ?/b st8/fr
Sta unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operator of the proposed establishment ever held a body art
establishment Iicense or permit?
Ifyes, please list the information belov'. Attach addilional pages ifnecessary'
D Yes
trNo
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/S uspended)
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
Please list and s ct all B Art Technicians tattoo,terct enlice
Type ofBody Att
Performed
Employee Name
Cteated 1124D023
\N?\i tutt
2