HomeMy WebLinkAboutJerrad DerossettTHE COMMONWEALTH OF MASSACHUSETTS
TOWNOFYARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-035
This is to Certifo tlnt Jerad Derossett
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformiry with the authonty granted to the Board of Health, by Chapter 140.
Sections 5 l, ofthe General 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 ofthe occupation so licensed as adopted by the Board ofHealth, and
exptes December 31, 2024 unless sooner revoked.
Jantary 1,2024, BOARD OF HEALTH:
(date)
Hillard Boskev, M.D., Clmirman
Mnrv Crais. Vice Chnirmnn ClnrlesHoli,nv, Clirk
Eic Weston
Laurance Venezia, DVM
James G. G
Direc h
FEE: $55.00/ Technician
/1.-
TOWN OF YARMOUTH Bosrd of
Hc.lrh
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DivirionTckphone (50t) 39&2231, eic I
Fu (50E) 76G3a72
Tvoc ofAoo&rrim
ENew fl neoewat Applicatim FE(s): 3160 / Frdlity $55 / Tecbniciu $5!l / Appra*ice
Tp{s)ofBodytut trTdooFrcility
tr Piercing FacilitY
ESTABIJSEIiEITT IIYFOB.UATT(,N
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Typcof omcnhlp: tr SolePropietor tr Corpcaion D Proership
If establishem is ovmcd by a corporcion, pemship, or other combindion of indivi&rals, please
attrch the mm€, title, tor ID#, md homc address of all owners.
Elt$S&ruf,t (}trur'r l IocLnHur Nue:
o
l,ast Middle Initial
a)(only)
t t4 v Cr%bdsnn dd
f fanoofectolcim tr APPnntice
tr Piercing Tecbnician
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HEAITH DEPI
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Phone
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C}.&d 121
l115 ROUTE2& SOUTH YARMOUTH,
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HEALTH DEPT,
Hrs the owner or opcrrtor ofthe proposed esteblishment ever held a body art
technicirn licensc or pcmit?
If yes, please list the information below. Attach additional pages d necessary.
!No
State/Municipality Lic./Cert./Reg. #(a Status (Active/Expired/Suspended)
tate/M palrty Lic./Cet./Reg. #
Hes the owner or operetor ofthe proposed estrblishment ever held a body art
estrbli$hment license or permit?
If yes, please list the informaion below. Attach additional pages if necessary.
Satus (ActiveiExpired/Suspended)
E Yes
trNo
State/Municipality Lic./Cert./Reg. #Shtus (Active/Expired/Suspended)
StateMunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmolth tsca rnd lienE must be paid prior to renewd or issuance of your pcrmits'
Please check appropriately if paid: Yes No
EMPLOYEE INFORMATION
Please list and s all entice
Type ofBody Art
Performed
Employee Name
z
Cr.ad tn4D
trutt ? U i,i)71
PRIOR LICENSIJRE
Art Technicians
Requirements for Body Art Esteblishment Permit
Submit the following to complete your application:
A copy ofowner's valid identification card with picture
(state-issued license, passport or military-issued to)
Detailed floor and opemtioa pla,ns of proposed body art establishment (new rpplicrnh only)
A copy of Blood Exposure Control Plan
Proof of liability insuance / Workman's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Medical Waste Re.nroval Contact
Bloodboroe Pathogen Training
Aftercare infomution and instructions
Applicrnt Stetement of Consent
I underrterd thrt thi! pcrntt is velid only in the Town of Yrmouth end expirc* rt the end of
the cdcndry yelr in which it wrs irsued. I rbo utrdentrtrd thrt rny notice to bc mrilcd to me by
the Town of Yemon& Boerd of Eertth will bc mriled to the rddress indic.ted on thir
application
I hrve rcccived r copy of the Ymouth Boerd of Hedth Body Art Reguletions. I hevc rcrd
md utrdetrtrnd tlc obligrtiou rnd requircmeu8 imposed upon e licenscd Body Art
Esteblishnent Owner/Opcntor by thoce rtguhtions. I dso rgrce to comply with ell of the
rcgulrtbn rrquirrments rpocificd itr tbo Yrrmouth Borrd of Heelth Body Art Regulrtions
while precticing in tte Town of Yemouth.
I further undcntend thet it ir rny relponsibility to ensurt thrt individual Body Art Techniciens
working in ttir ecteblirhmeut hlve a current vdid Yamouth Boad of Heelth Body Art
Technicirn Lietuse end comply with dl epplicrble herhh, srfety, srnitation, sterilization, end
work pncticcr rcguhtionr rs qpcciH in the Yrrmouth Boerd of Hcdth Body Art
Reguhtions.
I hereby certify, under pcneltier rnd prins of pcrjury, thet to the best of my knowlcdge the
informrtion provided on this rpplicrtion is complete end eccurrte rnd in no wey misrepraented.
rlLrrad oLros[ff,
,ilJi\ ./ 0 ?0?4
D
HEATTH D trDr-
Full rlne of Applicrnt
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Dete
It is your rerponsibility to renew your permit rt the cnd of eech calendar year.
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