HomeMy WebLinkAboutKaegan CotieTHE o ALTH F MASSACHUSETTS
TOWN OT'YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER:#24-032 FEE: $55.00/ Technician
This is to Certifo that Kaeean Cotie
at Snilt 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, oftheCeneral Laws, and amendments thereto, and is subject to the provisions ofihe 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 occupalion so licensed as adopted by the Board ol Health, and
expires December 3l , 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:Hillnrd Boslcey, M.D., Chnirmnn
Maru Crais, Vice Chairman CharlesHoli'av, Clerk
Eic Weston
Laurance Venezia, DVM
(date)
James G.
th
Tvpe of Aoolication
p New Q' .(enewal
I
Type(s) ofBody Arr trTattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INI'IORMATION
s
Nanre &
itv
First
Date B
/netpr 3r
TOWN OF YARMOUTH
l t46 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS02664-24451 Health
Telephone (508) 39E-2231, ext. l24l
Fax (s08) 160-3472
Application Fee(s): $160 i Factlity $55 / Technicisn $55 / Apprcntice
f fattoofecnnician O Apprentice
tr Piercing Teclrnician
q8 0u/<. {8
State zip
D Partnenhip
o
Last Middle Initial
Gender Tax ID
Board of
Healtt
Typc of ownerrhip: tr Sole hopriaor tr Corporation
Ifestablirhment is ormed by a corporation, partnership, or other combination of individuals, please
utu"tr tft *rn", titte, tax fO#, and home address of all oumers'
Establbhment Owner's / Technicians Ntme:
E frN
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e
/Ee loa e-
ziptate
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I
REGEVED
JUN 2 0 2024
HEALTH DEPI
Phone N Address
cnatcd lD4D023
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EGEUT/ED
b"dy[.3 o 2ffi4ves
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PRIOR LICENSURE
H"r the o*ne. or operator of the proposed establishment ever held
1q[!gi4 license or Permit?
s, please lis the
tate/I,lunicipali l,ic./Cert./Reg. #
rmation below. Attach tional esl nece
Status (Active/Exp
Lic./Cert.iReg. #Status (Active/ExPired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or Permit?
tfyrt, ptrou titt the information below. Attach additional pages dnecessary'
E Yes
trNo
State/Municipality Lic./Cert./Reg. #Setus (Active/Expired/Suspended)
StateiMunicipality Lic./Cert./Reg. #Status (Active/Expired/S uspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issugnce of your permits'
Please check appropriately if paid: Yes-No
EMPLOYEE INFORM ATION
Please list and s all Art Technicians tatloo,terct tice
Type ofBody Art
Performed
Employee Name
2
crcated I n4n023
State/lr4unicipality
knzeau (o--rz
?
Date
It is your responsibility to renew your permit at the end ofeach calendar year.
3
Signatu
Ctezt d |24n023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
I A copy of owner's valid identification card with pictue
(state-issued license, passport, or military-issued tl)
D Detailed floor and operation plans of proposed body art establishment (new applieants only)
! A copy olBlood Exposure Control Plan
! Proof of liabiiity insurance / Workman's Comp. lnsurance
D Client application and consent forms
D First Aid and CPR certifications
! Medical Waste Removal ConEact
! Bloodbome Pathogen I'raining
n 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 was issued.l abo understand that any notice to be mailed to me by
the Town of iarmouth 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 OwneriOperator by those regulations. I also agree to comply with all of the
regulation requirements specified in the Yarmouth Board bf Health Body Art Regulations
while practicing in the Town 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 and comply with all applicable health, safety, sanitation, sterilization, and
work practices regulations as specified in the Yarmouth Board of Health Body Art
Regulations.
I hereby certify, 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 Name of Applicant
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