HomeMy WebLinkAboutAlica KohutNWEALTH OF MASSACHUSETTS
TOWN OT- YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 4 24-051 FEE: $55.00/ Technician
This is to Certifo that Alica Kohut
at SniIt 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, ofthe GeneralLaws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health. and
expires December 3l , 2024 unless sooner revoked
Jautarv 1,2024. BOARD OF HEALT'H:Hillard Boskev, M.D., Clmirnmn
Mant Crnip, Vice Clnirmnn ChnrlesHold,ay, 1erkEic Weston
Lnurance Venezin, DVM
(date)
James G.
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02564'2445I
Telephone (50t) 39U223l,exL 1241
Fax (50E) ?6G3a72
Bosrd of
Hctldt
Healtr
Division
Tvoe of Aoolicetion
ENew fl Renewal Applicuioa Fee(s): $160 i Frcility $55 / Technicirn $55 / Apprentice
/ fattoofectnicim tr APPrcntice
n Piercing Technician
u/< ,/8
Type(s) ofBody Art D Tattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INFORMATION
Sorrt [Ai]LBffiNattt"E
State P
Ilpc of ownenhlp: tr Sole ProEietor tr Corporation n Pffirership
If establisbmelrt is owned by a corporation, Partnership, or other combination of individuals' please
attach the name, title, tax ID#, and home address of all owners'
Ectrblithnent Owner'g / Techrlclarr Nrme:
r/4.Koh* t
0
Middle InitialFirst
L qt
of Tax
Email
0
/kt/3
'l tutt
C
a
1
f-. Ctr
Cftard lD4Dt
Last
r
PRIOR LICENSUR-E
H"* ihe o*ner or operator ofthe proposed establishment ever held a body art zfles' lNotechnician license or Permit?
h addi ional pages if necessary.4pllistnformalion below. AtOZ
S cipality Lic./Cert./Reg' #Status (Active/Expired/Suspended)
State,4r4unicipality Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
Has the owner or operotor of the proposed establfuhment ever held a body art
estrblishment license or Permit?
Mt titt the information below. Attach additional pages dnecessary'
E Yes
trNo
State/IrdunicipalitY Lic./Cert./Reg. #Status (Active/ExPired/SusPend ed)
State/lr4unicipality Lic.iCert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmouth trxes and liens must be paid prior to renewal or issuance of your permits'
Please check approPriatelY ifPatd: Yes No
EMPLOYEE INFORIVIATTON
nticePlease list and s all Arl Technicians iattoo,ercli
Type ofBody Art
PerformedEmployee Name
cte*ed ll24D0
2
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification oard with- picture
(state-issued license, passport, or military-issued to)
! Detailed fl,oor and operation plans ofproposed body art establistunent (new applicants only)
! A copy ofBlood Exposure Control Plan
n Proof of liability insurance / Workman's Comp. Insurance
D Client application and consent forms
! First Aid and CPR certifications
n Medical Waste Removal Contract
n Bloodbome Pathogen Training
tr Aftercare information and instructions
Applicant Statement of Consent
I understand that this permit is valid only in the Town of Yarmouth and expires at the end of
the calendar year in wiich it wes issued. i also understand that rny notice to be mailed to me by
the Town of iarmouth Board of Heelth wilt be mailed to the address indicated on this
application.
I have received a copy ofthe Yermouth Board of Health Body Art Regulations' I have read
and understrnd the obtigations and requirements imposed upon a licensed Body A1t
Estrblishment owner/operator by those regulations. I also agree to comply with all of the
regulation requirements specified in the Yarmouth Board of Health Body Art Regulations
while practicing in the Town of Yermouth.
I further understend that it is my responsibility to ensure that individual Body Art Technicians
working in this establbhment have a current valid Yarmouth Board of Health Body Art
Technician License and comply with alt applicrble health, safety, sanitation, sterilization, and
work practices regulations as specified in the Yermouth Board of Health Body Art
Regulations.
I hereby certify, 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 misrepresented.
tlrL h.urch
Full ame of plicant
It is your responsibility to renew your permit st the end ofeach calendar year'
Creoted I /24,20
3