HomeMy WebLinkAboutJustin RodriquezHEC MM NWEALTH OF MASSACHUSETTS
TOWN O}'YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-054 FEE: 555.00/ Techrician
This is to Certiry that Justin Rodriouez
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 to the Board of Health, by Chapter 140,
Sections 5l , ofthe General laws, and amendments therdto] and is subject to the provisions ofihe LaiNs ofthe
Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulalions in regard to the carrying on of the occupation so licensed as adopted by the Board of Health, and
expires December 3 I , 2024 unless sooner revoked.
January I ,2024. BOARDOFHEALTH:Hillnrd Boskey, M.D., Chnirmnn
Mnru Crais, Vice Cluirman Chnrles
Holioav, ClirkEic Weston
Laurance Venezia, DVM
(date)
/ :".n*ccEir.,*/ Direcr6?'5f-Health
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 0256+2445I
Telephone (50E) 39S223l,exL l24l
Fax (50t) 76C3472
Board of
Hcalth
Hc.ldl
Divigion
TVoe of Aoolicrtion
E New fl Renewal Applicatioa Fee(s): $160 / Faciltty $55 / Technicirn $55 / Apprcrtice
Type(s) ofBody Arc tr Tattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INFORMATION
Snrtt ftiu r(q8 0uft '28
BGilessEame-&
lp
Type of ownenhip: tr Sole Proprietor 11 Corporatioa D Prmorship
If €stsblisbment is oumed by a corporation, putnership, or other combination of individuals, please
attach the nanre, title, tax ID#, and home address of all owners'
Ertrblrtmcnt Orvner'r / Tec.hnlchnr Nrmc:
r)c ueL L
First Last Middle Initial
(t C)
ax ID
State
L
zip
-(o"/l
f fattoofe*oician tr APPrentice
tr Piercing Technician
Z
1
Number
l0t/rJ
Cft,,fd lD{ta
PRIOR LICENSURE
tf"- tn. "**" ". "perator
ofthe proposed establbhment ever held a body art
technicien license or Permit?
s ease lisl the information below. Altach additional pages ifnecessary
unicipality Lic./Cert./Reg. #
State/M ty Lic./Cert./Reg. #
123 I 0o r+t
S
trNo
Status (Active/Expired/Suspended)
Status (Active/ExPired/Suspended)
E Yes
trNoHastheowneroroperstoroftheproposedestablishmenteverheldabodyart
establishment license or Permit?
ffir* titt the information below. Attach additional pages if necessary'
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
StateMunicipality Lic./Cert./Reg.Status (Active/Expired/Suspended)
Town of yarmouth trxes and liens must be paid prior to rtnewal or issuance of your permits'
Please check appropriately if paid : Yes No
EMPLOYEE INFORJUATION nticePlease list and s.all Art Technicians oo,tefcl
#
I
Type ofBody Art
PerformedEmployee Name
)
Crce,:.d ln4n0
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
n A copy of owner's valid identification card with, picture
(state-issued license, passport, or military-issued to)
! Detailed floor and operation plans ofproposed body art establishment (new applicants only)
! A copy ofBlood Exposure Contol Plan
! Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
! First Aid and CPR certifications
I Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftetcare 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 atso understand that any notice to be mailed to me by
the Town of iarmouth Board of Health will be mailed to the sddrcss indicated on this
application.
I have received a copy ofthe Yrrmouth Borrd of Heelth Body Art Regulations. I have reed
cnd understlnd the obligations and requirements imposed upon a licensed Body Art
Estebtishment Owner/Operator by those regulations. I also agree to comply with all of the
reguletion requirements specified in the Yarmouth Board bf Health Body Art Regulations
while precticing in the Town of Yermouth.
I further understand that it is my responsibility to ensure that irdividual Body Art Technicians
working in this establishment have a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicablc health, safety, sanitation, sterilization, and
work practices regulations es specilied in the Yarmouth Board of Health Body Art
Regulations.
I hereby certis, under pensltiB ind pains of perjury, that to the best of my knowledge the
informetion provided on this apptication is complete and accurate and in no way misrepresented'
r)r
ofApplicant +l0
te
It is your responsibility to renew your permit at the end of each calendar year'
3
ignatu
cr€dcd I /24,20