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Home My WebLink AboutC LombardiTHE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTII FEE: $55.00/ Techrician This is to Certifu that C Lombardi 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 subjectto 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 of the occupation so licensed as adopted by the Board ofHealth, and expires December 31, 2024 unless sooner revoked. January 1,2024, BOARD OF HEALTH:Hillard Boskeu, M.D., Chairman Moru Craiq. Vice Chnirman Charles Holi,av, C-lerk Eic Weston Laurnnce Venezia, DVM (date) James Gardinerf IJealth PERMIT NUMBER: # 24-050 ,-4^^--.(a^a...-- I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSET'TS 02664-24451 Telephone (508) 398-2231, ext. l24l Fax (508) 760-1472 Board of Health Health Division iui\ .) Tvoe of Aonlicetion t THO (u/4 I EPr ! New d Renewal ApplicationFee(s): $160iFacility $55/Technician $55 Type(s) ofBody Ar[ D Tattoo Facility D Piercing Facility ESTABLISHMENT INFORMATION SniLt M, r(0ulc {8 Busirless Name'& lil. ururnrtu*h l\/ 4-a7b?1Ciryt - Typc of ownerchip: tr Sole Proprietor tr Corporation D Partnership If establishment is owned by a corporatior5 partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all owners. Establilhment Owner's / Technicisnr Nrme: (,k-ornhn'2,r. ,..d Tattoo Technician tr Apprentice tr Piercing Technician First Last Gender TaxID#( Middle Initial only)f 6[f Vumonrsc Legal Mailing Address ?t'ltt)t)NV 1? zL3elE- +t u-to|,rs3b State zip C . t 0 rn batat, fatuerA a "m@/.to/hEmail Address 1 Phone Number crcttgdlD4D02 TOWN OF YARMOUTH toltol ,r a lW HE4 Eprrf11 l)PRIOR LICENSURE Has the owner or operator of technician license or permit? the proposed establishment ever hcld a bodya lf yes, please list the information below. Attach additional pages if necessary. CS !No State,Municipality Lic./Cert./Reg. #Status (Active,lExpired/Suspended) lCrpality Lic./Cert./Reg. #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 (ActivelExpired,/Suspended) State,Municipality Lic./Cert.iReg. # Status (Active/ExpirediSuspended) 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 cl all B Art Technicians attoo,terctn a nlice Employee Name Type ofBody Art Performed 2 Created lD4D023 N Y lrrit s LAK- ( t* o.gE h I I I I Requirements for Body Art Establishment Permit Submit the following to complete your application: D A copy ofowner's valid identification card with picture (state-issued license, passport, or military-issued rD) ! Detailed floor and operation plans ofproposed body art establishment (new applicants 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 Bloodbome Pathogen Training Aftercare information and instructions ! tCd €pt ! n !h U D 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 hsve 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 of perjury, that to the best of my knowledge the information provided on this application is complete and accurate and in no way misrepresented. Utris Lorn/a-2, Full Name o Applicant Da It is your responsibilit"v to renew your permit at the end ofeach calendar year. Z .1 Signat Created I D4D023 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.