HomeMy WebLinkAboutMatthew CreaseyJames G.
Director
THE COMM NWEALTH OF MASSACHUSETTS
TOW}{ OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00i Technician
that Matthew Creasey
at SnlIt 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 5l , ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe 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 bythe Board ofHealth, and
expires December 31. 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:Hillard Boskey, M.D., Chnirman
l)/lnry Cra1g, Vice Chnirman Chnrles
t1ol70nv, LletK
EicWeston
Laurance Venezia, DVM
(date)
Health
PERMIT NUMBER:# 24-034
This is to Certiry
TOWN OF YARMOUTH
1146 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS 02664'2445 I Health
Telephone (50E) 398 2231, ext. l24l
Fax (50E) 760-3472
Tvpe of Aoolicgtion
p New O- .(enewal Application Fee(s): $160 / Faciltty $55 / Technician $55 / Apprtn
Type(s) of Body Aft DTattoo Facility
I Piercing FacilitY
ESTABLISHMENT TNFORMATION
q8 0uft ,28(IJ
Name &
7b
lty State
Type of owncnhlp: tr Sole Proprietor tr Corporation
tf eSablishmenr is owned by a corporatio4 partnership, or other combination of individuals, please
attach the name, title; tax ID#, and home address of all ouners'
Establithment Owner's / Technicisnr Name:
Board of
Health
f rattoo re*niAan tr APPrentice
tr Piercing Technician
zip
D Pafinemhip
JUN 2 0 2024
HEALTH DEPT
EN EOSE
Last
0a
B Gender axID#(ishment only)
C
Middle InitialFirst
a3
City State
thccrels6o 4ql an
1
Phone Number
/
Crest l lD4D0l3
0
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or Permit?
@itt the informdtion belov'. Attach additional pages if necessary''
PRIOR LICENSURE
ffir th-" ot *. or operrtor of the proposed establishment
199[ig!4 license or Permit?
on low ttach qddit sdnecessary.ase list eln ional PaSe
! Yes
trNo
Sratus (Active/Expi
Status (Active/Expired/Suspended)
Status (Active/ExP ired/Swpended)
Status (ActivelExpired/Suspended)
renewal or issuance ofyour permits'
nlice
S untclpality l,ic./Ce(eg.#
State/lr4unicipality Lic./Cert./Reg. #
State/Municipality Lic./Cert./Reg. #
State,&luniciPalitY Lic.icert./Reg. #
E YEE IN FORMATION
Please list and all Art Technicians
Town of Yarmouth taxes and liens must be paid prior to
Please check appropriately if paid: Yes- No
luItoo,lercl
JUN ? O Zr,?4
EOQeoF
L-tr
Type olBody Art
PerformedEmployee Name
2
Crcated I r24no23
E Yes
trNo
Requirements for Body Art Establishment Permit
Submit the following to complete yow application:
! A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued Io)
! Detailed floor and operation plans of proposed body art establishrnent (new applicents only)
tr A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Ins
D Client application and consent forms
n First Aid and CPR certifications
n Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftercare inforrnation and instructions
JUN ? U 7tt?4
HEALIH DEPI
Applicant Statement of Consent
I understand that this permit is valid only in the Town of Yarmouth snd expires at the end of
the calendar year in wf,ich it was issued. I also 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 owner/operator 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 thlt 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 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.
Trlfld SE)
F Name of pplicant
/
Date
It is your responsibitity to renew your permit at the end ofeach calendar year,
.)
Signa
Crcated lD4D023
tr