HomeMy WebLinkAboutRobert FlayJames G
Director
THE COMMO ALTH OF MASSACHUSETTS
TOWN OF YAR.II{OUTH
BOARD OF HEALTH
PERMIT NUMBEP.: # 24-029 FEE: S55.00/ Technician
This is to Certifo that Robert Fav
at Soilt 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, anii amendments theretol and is subject to the provisions ofihe Laws oftheCommonwealth of Massachusetts relating therelo, and upon such terins and coirditions, and to the rules andregulations in regar-d_ to-th-e carrying on ofthe occupation so licensed as adopted by the Board ofHealth, andexpires December 31, 2024 unless sooner revoked.
Januarv I ,2024. BOARDOFHEALTH:Hillard Boskev, M.D., Chnirmnn
Mara Craiq. Vice Chnirmnn ChnrlesHoli,ny, Clerk
Eric Weston
Laurance Venezia, DVM
(date)
ner
ealth
TOWN OF YARM OU TH
1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664'2445I
Telephone (50E) 39E 223'1, ext. 1241
Fax (50E) 760'3472
Board of
Health
Hcolth
Division
TvD€ of Aoolication
p New O- .(enewalI
Application Fee(s): $160 / Facllity $55 / Technician $55 / Apprertic*
Type(s) ofBody Afi D Tattoo Facility
tr Piercing FacilitY
ESTABLTSHMENT INFORMATION
,d tattoo Tecnnician tr APPrentice
tr Piercing Technician
uft 180e\J
Narne &
(p
ry State
Type of ownemhip: tr Sole Proprietor D Corporation
If e$ablisbmenr is oumed by a corpordion, partnership, or other combination of individuals, please
attach the name, title;tax ID#, and home address of all owners'
tlshment Owner's / Technlcianr Name:
zip
tr PartroshiP
BEP r {tr
Last
Gender
Middle InitialFirst
6L
Date
utr
Tax
State
#only)
a
zip
0
c
it
1
Phone N
4-q 0
Address
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PRIOR LICENSURE
Ha. th" ot"n"r or operator ofthe proposed establishment ever held a body art tr Yes
technician license or permit?!No
ease list the i tion be Attach additional pa s d necessary.s,
unicipality Lic./C ./Reg.# 37 Status (Active/E xpl uspended)
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operstor ofthe proposed establishment ever held a body art ! Yes
establishment license or permit?nNo
Ifyes, ptease list the information below. Attach addilional pages if necessary.
State,Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/I4unicipality 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
EMPLOY EE FORMATION
Please list and s all Art Technicians tattoo,terc ntice
Type ofBody Art
Performed
Employee Name
2
cteated I l24DA23
.' , U l.it'?'o
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 m)
! Detailed floor and operation plans of proposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
I Proof of liability insurance / Workman's Comp. Insurance
D Client application and consent forms
! First Aid and CPR certifications
! Medical Waste Removal Contract
tr 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 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 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 compty with all applicable health, safety, sanitation, sterilization, and
work practices regulations as speci{ied 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 and accurate and in no way misrepresented.
KtseBr fr Fnl
Full Name of Applicant
1,1
Date
It is your responsibility to renerv your permit at the end of each calendar year.
3
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Crcated lD4D023