HomeMy WebLinkAboutJesse BlatzTHECOMMONWE TH OF MASSACHUSETTS
TOWNOFYARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-030 FEE: $55.00/ rechnician
This is to Certifu that Jesse Blatz
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with tbe authoriry granted ro the Board of Health. by Chapter 140,
lections 5l , ofrhe 9eneral Laws, and amendments therritol and is subject ro the provisions ofihe Laws ofttreCommonwealth of Massachusetts relating thereto, and upon such terins and coiditions, and to the rules andregulations in regard_ to^th-ecarrying on ofthe occupation so licensed as adopted by the Board of Health. andexpires December 3l , 2024 un.less sooner revoked
Januarv .2024.BOARD OF HEALTH:Hillard Boskey, M.D., Chairman
Mnrv Crais, Vice Chairman CharlesHolioay, Clirk
Eic Weston
Laurance Venezia, DVM
(date)
James G. G
Director
TOW N OF YARMOUTH Board of
Health
Tvoe of Aooliestion
p New O-tenewal
Type(s) ofBody ArL D Tattoo Facility
tr Piercing FacilitY
ESTABLTSHMENT INFORMATION
r.
U
Name &
ty
Establbhment Owner's / Techtricians Name:
Je sse bmr'z
First Last
c?tb r/)
Date B Gender
E UfrTfrL3T
0Kn c
City State
Application Fee(s): $160 / Facility $55 / Technician $55 / Apprenticc
/ fattoo fe*nician tr Apprentice
tr Piercing Technician
q8 0uft18
Type of ownenhip: tr Sole Proprietor tr Corporation tr Pafinership
If estahlishmmr is ourned by a corporation, partnership, or other combination of individuals' please
atach tho oame, title, tax tD#, and home address of all ouners'
State
TaxID#(
(?
ip
Middle Initial
oniy)
L A
20 -6 /t/q/*/a //oos mul
1
Phone Number
6'o'ua
Address
@.
Cre'[cn v)4D01
I146ROUTE28,SOUTHYARMOUTH,MASSACHUSEfiS0266/.2M5lHealth
Telephone (50E) 39E-223'1, ext' 1241 Division
Fax (50E) 760'3472
E
Y 001 B
PRIOR LICENSURE
Has tn. owner or operator ofthe proposed establishment ever held a body art
technician license or permit?
Ifyes, please list he in mation belo A ach additiAO}O.sifnecessary,o I
! Yes
trNo
Status (Active/Exp uspended)S unlclpaliry Lic./Cert.g.#
State/lvlturicipal ity Lic./Cert./Reg. #Starus (Active/Expired/Suspended)
Has the owner or operetor of the proposed establishment ever held a body art
establishment license or Permit?
tJyes, pteat, list the information belou'. Attach additional pages ifnecessary'
D Yes
trNo
State/Municipality Lic.iCert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #Status (Active/ExPired/Sus pended)
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
nticePlease list and s cl all Art Technicians tattoo rerct
Type ofBody Art
Performed
Employee Name
2
Craatad \ n4n023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy of owner's valid identification card with pictwe
(state-issued license, passport, or military'issued to)
! Detailed floor and operation plans of proposed body art establishment (ncw appliconts only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
f} Client application and consent forms
! First Aid and CPR certifications
n Medical Waste Removal Contract
n Bloodbome Pathogen Training
N Applicant
3E hLnrz u c 204
Da
It is your responsibility to renew your permit at the end ofeach calendar year'
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 witl 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 Heatth 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, sanitstion' sterilization, and
work practices regulations as specified in the Yarmouth Board of Health Body Art
Regulations.
I hereby certify, 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.
I!
3
Signature
Crcated 1 D4D023