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Home My WebLink AboutMichael PancielloPERMIT NUMBER: # 24-052 ONWEALTH OF MAS TOWN OF YARMOLITH BOARD OF HEALTH Michael Panicello FEE: $55.00i Technician E This is to Certifr that at SnlIt 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, oftheGeneral Laws, and amendments thereto, and is subject to the provisions ofihe Laws ofth6 Commonwealth of Massachusetts relating thereto, and upon such terms and coirditions, and to the rules and regulations in regqd to the carrying on ofthe occupation so licensed as adopted by the Board of Health. andexpires December 3 l, 2024 unless sooner revoked. Jantary 1. 2024. (date) BOARD OF HEALTH:Hillnrd Boskry, M.D., Clnirman Mara Crnis. Vice Chairmnn ChnrlesHoli,av, dirk Eric Weston Laurance Venezia, DVM James G th TOWN OF YARMOUTH I146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02ffi24451 TelePhone (50E) 39AZ?3|, exL 1241 Fax (508) 760'3472 BosIal of He8lth Healtt Division Tvoe of Apolicetion ENew fl Renewal Application Fee(s): $160 / Frciltty $55 / Technicirn $55 / Apprentice /fattootecmician D APPrentict tr Piercing Technician Typ{s) of Body Art D Tattoo Facility tr Piercing FacilitY ESTABLISHMENT INFOR-iIATION s 0U Name& zip I}pe of owncnhip: tr Sole Proprietor tr Corporation D Partncrship If establisbment is ovned by a corporAion, Partnership, or other combination of individuals, please attach the nanre, title, tax IH, and home address of all owners' Estrblithmotrt OwDor'g / Tecrbnlclsrr NlEe: K First Last Middle Initial Tax #( sr L tate 0u-rc 18 L 1 /A*,? Cft,ed lD4tA Al )ch 0l f)t C / /,(D t PRIOR LICENSURE H"* th" oro"" or operrtor of the proposed establishnent ever held a body art !g!4ig@ license or Permit? tf yrt, pt*t, list the information below Attach additional pages if necessary' &)tes/o"o State/tvlunicipality Lic./Cert./Reg' #Status (Active/Expired/Suspended) tzu S cl Lic./Cert./Reg. #Status (ActiveiExPired/S uspended) E Yes trNoHas the owner or operator of the proposed establishment ever held a body art establishment license or Permit? Mitt the information below. Attach additional pages if necessary' State^4unicipality Lic./Cert./Reg. #Status (Active,Expired/S uspended) StateMunicipalitY Lic.iCert./Reg. #Status (Active/Exp ired/Suspended) Town of Yarmouth taxes and liens must be paid prior to renewat or issuance of your permits' Please check appropriately ifpaid: Yes_=-No EMPLOYEE INFORIVIATION ercl nlicePlease list and all Art Technicians attooI Type ofBody Art PerformedEmployee Name 2 Creatcd I /24D0 Requirements for Body Art Establishmert Permit Submit the following to complete your application: I A copy ofowner's valid identification card with picture (state-issued license, passport, or military-issued Io) ! Detailed floor and operation plans of proposed body art establishment (new applicants only) E A copy ofBlood Exposure Control Plan E Proof of liability insurance / Workman's Comp. Insurance E Client application and consent forms D First Aid and CPR certifications E Medical Waste Removal Contract ! Bloodbome Pathogen Training n Aftercare information and instructions Applicant Statement of Consent I understand thrt this permit is valid only in the Town of Yarmouth and expires at the end of the calendar year in wiich it was issued. i also understand that any notice to be mailed to me by tne io*n of iarmouth Board of Health will bc mailed to the eddr$s ildicated on this application. I have reccived a copy of the Yamouth Borrd of Heelth Body Art Regutations- I have reed and understand the oblgations and requirements imposed upon a licensed Body A1t Esteblishment owner/operator by those regulations. I also agree to comply with all of the regulation requirements specified in the Yarmoutb Board bf He6th Body Art Regulations while practicing in the Town of Yermouth. I further understand that it b my responsibility to ensure that individual Body Art Technicians working in this establbhment htve a current vrlid Yarmouth Bosrd of Heelth Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work practices regulations es specified in the Yrrmouth Board of Health Body Art Regulations. I hereby certify, under penslties and pains of perjury, that to the best of my knowledge the informetion provided on this application is complete and accurate end in no way misrepresented. Full Name of pplicant Date It is your responsibility to renew your permit 8t the end of each calendar year' 3 S ture credcd I /2420