HomeMy WebLinkAboutGreg DeHoedtTHE COMMOIYWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-031 FEE: $55.00i Technician
This is to Certifu that Grell DeHoedt
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENCAGE 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 thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so licensed as adopted by the Board of Health, and
expires December 31, 2024 unless sooner revoked.
lanuarv 1,2024, BOARDOFHEALTH Hillard Boskpv, M.D., Chnirman
Maru Crais. Vice Chairmnn Chnrles
Hohi,av, dirkEic Weston
Laurance Venezia, DVM
(date)
lner
alth(]
James G.
Tvoe of APolicetion
p New O. .(enewal
I
Type(s) ofBody Aft trTattoo Facility
D Piercing FacilitY
ESTABLISHMENT INFORMATION
S
tt Narne &
ity
ARMOUTH
/
TOWN OF Y
1146 ROUTE 28, SOUTH YARMOUTH, MASSAcHvlEfis
Telephone (50E) 39E-2231' ext' l24l
Fax (508) 760'3472
Application Fee(s): $160 / Faciltty $55 / Technicien $55 / Apprtntie
/fattoofecnnician o APPrurtice
tr Piercing Technician
0uft {8
b
State
Establishment Owner's /Technicians NsEe:
I
Type ofowncrrhlp: tr Sole Proprietor tr Corporation tr Pafinenhip
If esabtishoenr is ou,ned by a corporuion .
psrtnershi,p, or_other combination of individuals' please
uttu*, tfr. **", title, tax ID#, and home address olall owners'
E 4ar Df
.,ut\ ? 0 2024
EALTH DEPT.
Di
H
6 Middle Initial
First
/^a7
B
Last
Gender Tax ID (establo7so{ 3///6EL{NS LfrUE
Legal Address/6/a7//s
Stale
30{-Oea{
Email
1
Phone Number Address
cr. etln4Do,
Board of
Health
t]t\ ? 0 Z0Z4
r-..E
Ef,t)EPI!YPRIOR LICENSURE
Has the owner or operator of the proposed establishment ever
technician license or permit?
ease list t ation low. Attach additional pages if necessarY.
S
S unicipality Lic.//Reg. #tus (Acti uspended)
StateAvlunicipality Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
Has the owner or operrtor ofthe proposed establishment ever held a body art ! Yes
estab hment license or permit?trNo
Ifyes, please list the information belou'. Attach additiona I pages if necessary.
State/Municipality Lic./Cert./Reg. #Status (Active/Expired./Suspended)
State,Municipality Lic./Cert./Reg. #Starus (ActiveiExpired/Sus pended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately if paid: Yes-No
Please list and all Art Technicians talloo,rcrc ntices
Type ofBody Art
Performed
Employee Name
2
crcsf.ed I D4nA23
EMPLOYEE INFORMATION
!
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr A copy of owner's valid identification card with pictue
(state-issued license, passport, or military-issued to)
Detailed floor and operation plans of proposed body art establishment (new applkants only)
A copy ofBlood Exposure Control Plan
Proof of liability insurance / Workman's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Medical Waste Removal Contract
Bloodbome Pathogen Training
Aftercare information and instructions
Full N of
!
!
D
!
!
!
Applicant Statement of Consent
I understand thrt 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 undentand that any notice to be mailed to me by
the Town of Yarmouth Board of Heatth 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 ownerioperator 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 Yarmouth.
I further understand thst it is my responsibility to ensure that individuat Body Art Technicians
working in this establishment have a current valid Yarmouth Board of Health Body Art
Technician License and comply with alt applicable health, safety, sanitation, sterilization, and
work practices regulations as specified in the Yarmouth Board of Health Body Art
Regulations.
I hereby certi$, under penalties and pains of perjury, that to the best of my knowledge the
information provided on this application is complete and rccurate and in no way misrepresented.
6Prao ilcecr
t
b /o
te
It is your responsibililv to renew your permit at the end ofeach calendar year'
a
3
luN 2 0 ?024
Li
HEALIH DEPI
0vtrD
Srgnature
Created 1 D4D023