HomeMy WebLinkAboutDaniel McNamaraTH TH OF MASSACHUSETTS
TOWNOFYARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu tlnt Daniel McNamara
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 authonty granted to the Board of Health, by Cbapter 140,
Sections 5 I . ofiheGeneral Laws, and amendments thenitol and is subject to the provisions ofihe La",vs oftheCommonwealth ofMassachusetts relating thereto, and upon such terms and coiditions, and to the rules andregulations in regar-d_ to-th-e carrying on ofthe occupation so licensed as adopted by the Board ofHeaIh, and
expires December 3l , 2024 unless sooner revoked
2024 BOARD OF HEALTH:Hillard Boskerl, M.D., Cltnirnnn
Mara Crais. Vice Chairmnn ChnrlesHolil,au, ClerkEic Weston
Laurance Venezia, DVM
(date)
Jamcs G
Irh
PERMIT NUMBER: # 24-059
TO WN OF YARMOUTH
I146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02654'24451
Telephone (50t) 39V223l,exL 1241
Fax (50E) 76G3472
Board of
Hcslth
Hcdtr
Division
Tvoe of Aoolicetion
E New fl Renewal Application Fe(s): $160 / Frcittty $55 / Tcchnicirrn $55 / Apprertice
Type(s) ofBody Art tr Tattoo Fscility
tr Piercing FacilitY
ESTABLISHMENT INFORMATION
s
B Name &
First Last
lty
,,d tattoofecmician tr APPrentice
tr Piercing Technician
0uft ,/8
(?
1p
Middle Initial
Tax
/5ZZ/
zip
0t,
Tlpc of owncnhip: tr Sole Proprietor tr Corporation tr Patnemhip
If establishment is owned by a corporation, partnership' or other combination of individuals' please
attach the name, title, tax ID#, and home address of all owners'
Ectrbltfimoot Owner'r / Tec.hnldur Nuc:
M
1
Nrunber
-zt
Address
Crt,,,rd lD4la
PRIOR LICENSURE
H", th" "*"ilr ope.tor of the prop*ed establishment ever held a body art ffs
@@!gj4 license or Permit?
J,ease list the informationb d'r !,frrruoo. nZ
unicipality Lic./Cert./Reg' #
trNo
Status (Active/Expired/Suspended)
h tional s
I
State/I4unicipality Lic./Cert./Reg. #Status (Active/Expired/S uspended)
Hes the owner or operator ofthe proposed establishment ever held a body art
estabtishment license or Permit?
Mi* utt the information below. Attach additional pages if necessary'
L] YES
trNo
Status (Active/Expired/Suspended)StateMunicipalitY Lic./Cert./Reg. #
StateMunicipality Lic./Cert./Reg. #Status (Active/ExPi red/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
Please list snd all Art Technicians attoo,rct a lces
Type ofBody Art
PerformedEmployee Name
Creat.d I D4202
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 ro)
D Detailed fl,oor and operation plans of proposed body art establishment (new applicants only)
I A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp lnsurance
I Client application and consent forms
n First Aid and CPR certifications
! Medical Waste Removal Contract
! Bloodbome Pathogen Training
tr Aftercare information and instructions
Applicent Statement of Consent
I understrnd thrt this permit is valid only in the Town of Yarmouth and expires at the end of
tn"-cat.raa. y"ar in wiich it wes issued.l ako utrderstand thrt sny notice to be mailed to me by
the Town of iamouth Board of Heelth will be maited to the address indicated on this
application.
I have received a copy ofthe Yermouth Boerd of Heelth Body Art Regulations. I heve read
andunderstandtheobligationsandrequirementsimposeduponalicensednolya|
Esteblishment owner/operator by those regulations. I also agree to comply with all of the
reguletion requirements specified in the Yermouth Board bf Health Body Art Regulations
while practicing in the Town of Yarmouth.
I further understand thst it is my responsibility to ensure that individual Body Art Technicians
working in this establishment hlve a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, senitation, sterilization, and
work practices reguletions es specified in the Ycrmouth Board of Health Body Art
Regulations.
I hereby certify, under penslties and pains of perjury, that to the best of my knowledge the
informetion piovided on this "pplication is complete and accurate and in no way misrepresented'
l,./NA,VnA,fl-
Full Name Applicant
Da
It is your responsibilit"v to renew your permit st the end ofeach calendar year'
3
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