HomeMy WebLinkAboutNicholas FrenchkoTHE COMMONWEALTH OF SACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-053 FEE: $55.00/ Technician
This is to Certifu that Nicholas Frenchko
at SDilt 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 lo the Board of Health, by Chapter 140,
lections 51, oftheGeneral Laws, and amendments thenioland is subject to the provisions ofihe Lai,vs oftheCommonwealth ofMassachusetts relating thereto, and upon such terins and coirditions, and to the rules and
regulations in regar-d lo,thecarrying on ofthe occupation so licensed as adopted by the Board of Health, and
expires December 3l , 2024 unless sooner revoked
Januarv I .2024.BOARD OF HEALTH:Hillard Boskeu, M.D., Clnirman
Mnru Crais, Vice Chairmnn ChnrlesHoli,nv, Clirk
Eic Weston
Laurance Venezia, DVM
(date)
James G. G
Direcl th
TO WN OF YARMOUTH
1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664'24451
TelePhone (50t) 39V2231,qL 1241
Fax (508) 76G3472
Board of
He.hh
Healtt
Division
Tvoe of Aoolicetion
E New fl Renewat Application Fee(s): $f60 i Frcility $55 / Technicirn $55 / Approatice
Type(s) ofBody Art D Tattoo Facility
tr Piercing FacilitY
ESTABLTSHMENT INFORMATION
s
Name &
Last
,dTattooTechnician tr APPrentice
tr Piercing Technician
0u/< ,t8
(!
\pc of owncnhip: tr Sole Proprietor tr Corporation tr Patnsnhip
r€stsblfuh€fr is orrned by a corporation, pslbership, or other combination of individuals' please
attach tho name, title, tax ID#, and home address ofall owners'
Ect blbhmcnt Owner'r /Teclnfdau Neme:
Initial
Z
Tax )
(
City
/+I y 70L/
ziptate
b*,
1
Phone
- 52 (rul
C..ed lD4la
PRION. LICENSURE
H* th. *,n"t ". "peretor
of the proposed establishment ever held a body art
!gg@ig@ license or Permit?
ffit, tist the iiformation below. Attach additional pages if necessary'
Y"'nNo
State/Municipality Lic./Cert./Reg. #Sratus (Active/Expired/S uspended)
State/M c1 ity Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
n Yes
trNoHas the owner or operator ofthe proposed establishment ever held a body art
establishment license or Permit?
Mitt the information belot'. Attach additional pages if necessary'
State/lr,Iunicipal ity Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
StateMunicipalitY Lic./Cert./Reg. #Status (ActivelExpired/Suspended)
Town of yarmouth trxes and liens must be paid prior to renewal or issuance of your permits'
Please check appropriately ifpaid: Yes- No
EMPLOYEE INFORMATION nlicePlease list and all Art Technicians attoo ercl aI
Type ofBody Art
PerformedEmployee Name
)
Crc',:ud I D4D0
I't iFull Name of Applicant
3 Z
It is your responsibility to renew your permit at the end ofeach calendar year'
6
3
crested t /2410
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 Io)
tr Detailed floor and operation plars of proposed body art establishmenl (new applicants only)
I A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
E First Aid and CPR certifications
n Medical Waste Removal Contract
tr Bloodbome Pathogen Training
! Aftercare information and instructions
Applicant Statement of Consent
I understand thet this permit is valid only in the Town of Yarmouth and expires at the end of
the calendar year in wf,ich it wes issued.l aho understand that iny notice to be mailed to me by
the Town of iarmouth Board of Heelth will be mailed to the address indicated on this
application.
I have received a copy ofthe Yermouth Boerd of Heflth Body Art Regulations. I have read
end understand the obligrtions and requirements imposed upon a licensed Body Art
Esteblishment Owner/Operator by those regulations. I also agree to comply with all of the
reguletion requirtments specified in the Yermouth Boird bf Herlth Body Art Regulations
while precticing in the Town of Yermouth.
I further underrtrnd that it is my responsibility to ensure that individual Body Art Technicians
working in this estrblishment have a current valid Yarmouth Board of Health Body Art
Technician License end comply with all applicable health, safety, sanitation, sterilization, and
work practices reguletions as specified in the Yrrmouth Board of Health Body Art
Regulations.
I hereby certify, under penalties and pains of perjury, that to the best of my knowledge the
information piovided on this application is complete and accurate end in no wry misreprtsented.