HomeMy WebLinkAboutEric SchiweTHE COMMONWEAL A HU ETTS
TOWN OFYARMOUTH
BOARD OF HEAI,TII
FEE: $55.00/ Technician
This is to Certifu that Eric Schiwe
at SDilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments theriol and is subj ect to the provisions ofine Laws ofthd
Commonwealth ofMassachusetts relating thereto, and upon such terins and coiditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so Iicensed as adopted bythe Board of Health, and
expires December 31, 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:Hillnrd Bosktv, M.D., Chnirmnn
Marv Crais, V ice Chairmnn ChnrlesHolil'av. ClirkEic Weston
Laurance Venezia, DVM
(dat€)
James G
PERMIT NUMBER: # 24-058
E&!g.WENSUBE
Hss the owner or operator ofthe proposed establishment ever held a body art ! Yes
technician license or permit?o
ease list the i mati i
S unicipality Lic./Cert./Reg. #
s, pl nfor n below. At additional page s if ne c e ssaryC
Status (Activ Suspended)
State/\4unicipality Lic./Cert./Reg. #
Has the owner or operrtor ofthe proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information belou,. Attach additional pages ifnecessary.
Status (Active/Expired/Suspended)
! Yes
trNo
State/l\ilunicipality Lic./Cert./Reg. #Status (Active/ExpirediSuspended)
State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately ifpaid: Yes_No
Please list and all Art Technicians tsttoo,terct nlice
Employee Name Type ofBody Art
Performed
Creat d ID4/2023
EMPLOYEE INFORMATION
2
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS O2@2M51
Telephone (50E) 398-2231, exL 1241
Fax (508) 760'3472
Board of
Healtl
Healtr
Division
Tvoe of Aoolicedon
oNew /Renewal ApplicuionFee(s):$f60/Facility $55/Technician $55/Apprentice|"
Type(s) ofBody Art: D Tattoo Facility ,d Tattoo Technician tr Apprentice
tr Piercing Facility tr Piercing Technician
@
s 0uft ,28
Name &
7b
Slate ztp
Typc of ownenhlp: tr Sole Proprietor tr Corporation n Partnenhip
If establighment is owned by a corpor*ior1 parhership, or other combination of individuals, please
attach tlre name, title, tax ID#, and home address of all owners.
Estlblfuhment Owner's / Technicirnr Nrmc:
E<te Sc///u/E J-
First Last Middle Initial
o8
Date irth Tax ID
0 /DE DR
/o
State Zip
86a
Email Address
1
Phone Number
d
C'!'afii ll2420T
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr 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 of Blood Exposure Control Plan
I Proof of liability insurance / Workman's Comp. Insurance
tr Client application and consent forms
E First Aid and CPR certifications
n Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftercare information and instructions
Applicant Statement of Consent
I understand 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 urderstand that any notice to be mailed to me by
the Town of Yarmouth Board of Health 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 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
regulation requirements specified in the Yarmouth Board of Health Body Art Regulations
while practicing in the Towu of Yarmouth.
I further understand 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 snd comply with all appticabte health, safety, sanitation, sterilization, and
work practices regulations as speci{ied in the Yarmouth Board of Health Body Art
Regulations.
I hereby certiff, under penalties and pains of perjury, that to the best of my knowledge the
information provided on this application is complete and accurate and in no way misrepresented.
Full N of Applicant
Elt Scilaz 20)
Da
It is your responsibility to renew your permit at the end of each calendar year.
3
Signature
Crcd.ed lD4D023