HomeMy WebLinkAboutSara MarshallMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-056 FEE: $55.00/ rechnician
This is to Certifu Sara Marshall
Snilt Milkat
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, ofthe 9eneral I aws, and amendments thereto, and is subject to the provisions ofihe Laws ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and coirditions, and to the rules andregulations in regar-d_ to-th€ carrying on ofthe occupation so licensed as adopted bythe Iloard of Health, and
expires December 3 I , 2024 unless sooner revoked
lanntary 1,2024, BOARD OF HEALTH:
(date)
Hillnrd Boskeu, M.D., Chairrunn
Maru Craip, Vice Chairmnn ChnrlesHol 'av, Aerk
Eic Weston
Laurance Venezia, DVM
J G
th
TOWN OF YARMOUTH
I146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 026+24451
Telephone (50E) 398-2231' ext 1241
Fax (50t) 760'3472
Boaral of
Heslth
Healtt
Division
Type(s) ofBody Art tr Tattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INFIoRMATIoN
Tvoc of Aoolicrtion
0 New fl Renewal Applicarion Fee(s): $160 / Fecility $55 / Technicirn $55 / Apprtntice
f fanoofecUician tr APPn'lrtice
D Piercing Techtician
0ulc ,/8
5 [6rh a-e
First Last Middle Initial
0 Z
Tax ID #
s
B Name &
(?
Ity State
Typo ofowncnhlp: tr Sole Pnoprietor tr Corporatioa o Prtnership
If establishment is owned by a corporation, parOership, or other combination of inrlividuals, please
attach the name, tftle;tax ID#, and home address ofall owners.
ktrblbtmcnt Owner'r / Techddrnr Nrmc:
tq /-h Jt
l1 A/C
ty State
aa-l .cont
1
qoeb
Ct id lD4nl
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PRTOR LICENSURE
H"* th. o*o., or operetor of the proposed establishment ever held a body art
lggb4[l@ license or Permit?
ease Iis,mation below. Attach additi s if necessary.s
F",DNO
Status (Active/Expired/S uspended)
Status (Acti ve/ExPired/Suspended)
n Yes
!No
f
S unicipality
State/Municipality
Lic./Cert./Reg. #
Lic./Cert./Reg. #
Has the owner or operator of the proposed esteblishment ever held a body art
establishment license or Permit?
Mitt the information below. Attach additional pages if necessary'
State/Municipality Lic./Cert./Reg. #Status (Active/ExPired/Sus pended)
State&Iunicipality Lic.iCert./Reg. #Status (Active/ExPiied/Suspended)
Town of yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits'
Please check appropriately if paid: Yes No
EMPLOYEE INFORJUATION
oo erc t enticePlease list and s cl all Art Technicians
Type ofBodY Art
Performed
)
Cred.d lD4l20
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)
n Detailed fl,oor and operation plars of proposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
n Client application and consent forms
! First Aid and CPR cmifications
n Medical Waste Removal Contract
! Bloodbome Pathogen Training
I Aftercare information and instructions
Applicant Statement of Consent
I understand that this permit is valid only in tbe Town of Yarmouth and expires at the end of
the calendar year in wiich it wes issued. I also understend that any 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 Yarmouth Board of Health Body Art Regulations. I have read
and understsnd the obligations and requirements imposed upon a licensed Body Art
Establishment owner/operator by those regulations. I also agree to compty with all of the
reguletion requirements specified in the Ysrmouth Board bf Health Body Art Regulations
while practicing in the Town of Yermouth.
I further understrnd that it is my responsibitity 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 reguletions as specified in the Yarmouth Bosrd of Health Body Art
Reguletions.
I hereby certify, under penalties and pains of perjury, that to the best of my knowledge the
informetion piovided on this application is complete and accurate and in no way misrepresented.
Sara lV\a r h a//l
Full Name of Applicant
5
It is your responsibility to rene\u your permit at the end of each calendar year'
ZA
3
Signature
cteded I 124/20