HomeMy WebLinkAboutNathaniel KaschakJames G. G
Director of
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OT'YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-055 FEE: $55.00/ Technician
This is to Certifo that Nathaniel Kaschak
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 5l . ofthe General Laws, and amendments thereto, and is subiect to the provisions ofihe hws oftheCommonwealth of Massachusetts relating thereto. and upon such terms and coiditions, and to the rules and
regulations in regar-d. to-th-e carrying on ofthe occupation so licensed as adopted by the Board ofHealth, and
expires December 3l , 2024 unless sooner revoked
Hillord Boskey, M.D., Chairmnn
Mnrv Crais, Vice Clmirmnn ClmrlesHoli,au, Clerk
Eic Weston
Laurance Venezia, DVM
January1.2024. BOARDOFHEALTH:
(date)
TOWN OF YARMOUTH
1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETIS 02664.2445I
TelePhone (50E) 3 9V2231 , exL 1241
Fax (508) 760'3472
Board of
Hcdth
H€dtr
Division
True of Aoolicrtfun
D New fl Renewal Applicuion Fe{s): $160 i Faciltty $55 / Technicirn $55 / Approntice
Typ{s) of Body Art n Tanoo Facility
tr Piercing FacilitY
ESTABLISHMENT INFORMATION
Snrrt luilL OU/{ ,28
ffiessNamea
(!
Statf,z
Type of owncnhip: tr Sole Proprietor tr Corporation tr Prtnership
11' establfuh€rf is owned by a corporation, partnership, or other combination of individuals' please
attach tho name, title, tax ID#, and home address of all owners'
Ertrblbtmcnt Owncr'r / Technldau Nrme:
f
f fattootecmician D APPrurtice
tr Piercing Technician
irst Last Middle Initial
ax ID
702
+0-n I cc,m
N Email
1
CrEead ln4Dl
PRIOR LICENSURE
Hrs the owner or operator ofthe proposed estrblishment ever held a body art 2€LYes
!gg!E!q@ license or Permit?trNo
ase list on below. Attach addilional pages ifnecessary
S unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State,Municipality Lic./Cert./Reg. #Statrs (Active/Expired/Suspended)
Has the owner or operator of the proposed estlblhhment ever held a body art
establishment license or Permit?
tf y"t ptrou titt the information below. Attach additional pages ifnecessary'
E Yes
trNo
Lic./Cert./Reg. #Status (Active/ExPired/Sus pended)
Staie/lvlunicipality Lic./Cert./Reg. #Status (Active/Exp ired/Suspended)
Town of yarmouth taxes and liens must be paid prior to renewal or issuance of your permits'
Please check appropriately if paid: Yes-No
EMPLOYEE INFORMATION nlicePlease list and s all Art Technicians 'laIloo,ercti
Type ofBody Art
Performed
2 Crc cd 124D0
Statellr,lunicipality
Employee Name
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)
D Derailed floor and operation plans of proposed body art establishrnent (new applicanh only)
! A copy of Blood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
tr Client application and consent forms
D First Aid and CPR certifications
n Medical Waste Removal Contract
tr Bloodbome Pathogen Training
U Aftercare information and instructions
Applicant Statement of Conrent
I undentand thet 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 wilt bc mailed to the eddress indicated oD this
application.
I have received a copy ofthe Yarmouth Boerd of Health Body Art Regulations. I have reed
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
reguletion requirements specified in the Yermouth Board bf Hestth Body Art Regulations
while practicing in the Town of Yermouth.
I further underrtand 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, sanitation, sterilization, and
work practices regulations as specified in the Yarmouth Board of Health Body Art
Regulations.
I hereby certiS, under penalties and pains of perjury, that to the best of my knowledge the
informetion provided on this application is complete and accurate and in no way misreprtsented.
Nn nniil, Ka <('heK
Full Name of Applicant
v/ra
Date
It is your responsibility to renew your permit at the end of each calendar year.
3
ature
Creded l/2420