HomeMy WebLinkAboutRavyn TurriniTHE COMMONWEALTII OF MASSACHUSETTS
TOWN OFYARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifo that Rawn Turrini
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 of Massachusetts 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 ofHealth, and
expires December 31, 2024 unless sooner revoked.
Hillnrd Boskerl, M.D., Chnirman
llnry C ra1g, ! ice Cha i r m a n C hn rle s
tlolutav, LlerkEic Weston
Laurance Venezia, DVM
Januarv 1.2024. BOARD OF HEALTH:
(date)
J.^,^\rir,J)/ l;^:,,G Gldiner/ Directtrofliealth
PERMIT NUMBER: # 24-051
TOWN OF YARMOUTH
1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.2445I
Telephone (508) 398-2231, exL 1241
Fax (508) 760-3472
Board of
Health
Health
Division
Tvpc of Apolication
ENew flRenewal ApplicuionFee(s):$160i Facility $55/Technician $55/Apprentice| "
Type(s) ofBody Art D Tattoo Facility ,d Tattoo Technician tr Apprentice'/
tr Piercing Facility D Piercing Technician
ESTABLISHMEM INFORMATION
Sni rt r\,ti l(q8 Koutc {8
Busi ess Name'&
lll U r, rm rtv,*h fll + 12pa.ACity l -
Tlpc of ownerrhip: tr Sole Proprietor tr Corpomtion tr Parhrenhip
If establishment is owned by a corporatio& partnership, or other combination of inrtividuals, please
attach the name, title, tax ID#, and home address ofall owners.
Ectabfuhment Owner's / Technicianr Nue:
First Last Middle Initial
ad-
Date B Tax ID enly)(
5?7 R,ussetL 2D , frpr 7b
L,JesrniELb .nfr c/cscelv/
City tates zip
Email
1
Phone Number
@
Crcdtqd lD4D0?:
J'
! Yes
oeaselist the in
State,{r4unicipalily Lic./Cert./Reg. #
be low. Attach additional pages ifnecessary.+L
Status (Acti uspended)
State/Municipality Lic./Cert./Reg. #
n Yes
trNo
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
If yes, please list the information below. Auach additional pages ifnecessary.
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Please check appropriately ifpaid: Yes_No
Please list and s cl all B Art Technicians ctttOO,ercrn 0 nlice
Type ofBody Art
Performed
Employee Name
1
Crcat d 1n4D023
PRIOR LICENSURE
Has the olyner or operator ofthe proposed establishment ever held a body art
technician license or permit?
Status (Active/Expired/Suspended)
State,Municipality Lic./Cert.iReg. # Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
EMPLOYEE INFORMATION
n
n
n
n
n
n
n
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 applicants onty)
A copy of Blood Exposure Control Plan
Proof of liability insurance / Workman's Comp. Insurance
Cliant application and consent forms
First Aid and CPR certifications
Medical Waste Removal Conhact
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
regulstion 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 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 ofperjury, that to the best of my knowledge the
information provided on this application is complete and accurate and in no way misrepresented.
/
Full Name of Applicant
fr,d>,r^.{ '^ 'auw/s4ilffi.
Creei,td I D4/2023
It is your responsibility to renew your permit at the end of each calendar year.
3