HomeMy WebLinkAboutJason LesperanceTH F MASSACHUSETTS
PERMIT NUMBER: #24-060
TOWN OFYARIUOUTH
BOARD OF HEALTH
FEE: S55.00/ Technician
This is to Certifu that Jason Lesoerance
at Soilt 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,
lections 5l , ofthe,GeneralLaws, and amendments thereto, and is subject to the provisions ofihe Laws oftheCommonwealth of Massachusetts relating thereto, and upon such terms and coirditions, and to the rules and
regulations in regard to the carrying on olthe occupation so licensed as adopted by the Board of Health. and
expires December 31, 2024 unless sooner revoked
Januarv .2024.BOARD OF HEALTH:Hillard Bosketl, M.D., Chairman
Maru Crais. Vice Chairman Clnrles
Holionu, Airk
EicWeston
Laurance Venezia, DVM
(date)
James G.
th
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 0266+2445I
TelePhone (508) 39U2231,ext- 1241
Fax (50E) 76C3472
Board of
Hcahh
Healtt
Division
Tvoe of Aoolicrtion
E New fl Renewal Application Fee(s): $160 / Frcittty $55 / Technicirn $55 / Appraticc
Typ{s) of Body Art D Tattoo Facility
n Pietcing FacilitY
ESTABLISHMENT INNOR,MATION
S OUft18
B Name &
zip
Type of owncnhip: tr Sole Proprietor tr Corpomtion D Patn€lnhip
Il. establishmeot is ourned by a corporatioD, partnership, or other combination of individuals, please
atach the name, title, ta,x ID#, and homc address of all owners.
E trtffimcnt Olvncr's /Tcc.hddul Nue:
n e a-?
Last Middle Initial
IL rU
of ax ID
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1LL1-+[q.\o LLI I ar r nn d t latnwdila-@M a,l I .
f tattoofectoiciam tr APPrentice
tr Piercing Technician
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PRIOR LICENSURE
Has the o*ner or operator of the proposed establishment ever held a body art
gg@!g!4 license or Permit?
,please tist the infornatY*tT-8,1"rffiff YlrygVne ssary.es
S unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/tr4unicipality Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
Hss the owner or operator of the proposed estrblishment ever held a body art
establishment license or Permit?
ttyrt, ptrtu titt the information below. Attach additional pages if necessary'
O Yes
CNo
State,Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State,Municipality Lic./Cert.,Reg. #Status (Active/Expired/S uspended)
Town of Yarmouth trxes and liens must be paid prior to renewal or issuance of your permits'
Please check appropriately ifpaid: Yes.-=-No
EMPLOYEE INFORI'ATION
Please list and s all Art Technicians oo erct enticet
Type ofBody Art
Performed
,)
crcated I D4no
Pes, DNO
Employee Name
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr A copy of owner's valid identification card with- picture
(stat6-issued license, passport, or military-issued to)
tr Detailed floor and operation plans of proposed body art establishmenl (new applicants only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp' Insurance
D Client application and consent forms
I First Aid and CPR certifications
! Medical Waste Removal Contract
n Bloodbome Pathogen Training
f] Aftercare information and instructions
Applicant Statement of Consent
I undentand thet this permit is valid only in the Town of Yarmouth and expires at the end of
ihe calendar year in wiich it was issued. i also understand that any notice to be nailed to me by
the Town of iarmouth Board of Health will be mailed to the address indicated on this
application.
I hrve received a copy ofthe Yarmouth Boerd of Health Body Art Reguletions' I have reed
and understand the obtgations and requirements imposed upon a licensed Body A1t
Estebtishment Owner/Operator by those regulations. I also agree to comply with all of the
regulation requirements specified in the Yarmouth Board of Heatth Body Art Regulations
while precticing in the Town of Yermouth.
I further understrnd that it is my responsibility to ensure that individual Body Art Technicians
working in this egtablishment hlve a current valid Yarmouth Board of Health Body Art
Technician License and compty with all applicable health, safety, suitation, sterilization, and
work practices reguletions es specified in the Yrrmouth Board of Health Body Art
Reguletions.
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 accurate and in no way misrepresented.
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It is your responsibility to renew your permit at the end of each calendar year.
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