HomeMy WebLinkAboutNoah MortezTOW N OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS
TelePhone (50E) 39V2231, ext' 1241
Fax (508) 760'3472
Board of
Health
JUi\ 7 U ;10?4
HEAITH DEPI
Tvpe of Aoolicrtion
pNew 0' .(enewal Application Fee(s): $160 / Frctltty $55 / Technician $55 / Apprentice
Type(s) ofBody ArI DTattoo Facility
tr Piercing FacilitY
ESTABLTSHMENT INFORMATION
,.,d fattoo fecmician D APPrentice
tr Pietcing Technician
0U Uft {80s
Buslness Name &
Lb
State p
Type of ownenhip: tr Sole Proprietor tr Corporation D Partrership
If e$ablishmenr is ourned by a corporstion, partnenhip, or other combination of individuals' please
attach the name, title, tax ID#, and home address of all owners'
Estsblbhment Owner's / Technicisni Nrme:
fril 08tr7-S
First
2 a
Date Birth
Legal
Last
Gender
Middle Initial
Tax ID
State
)
/PIE DRtUE
/yc 274a1
zip
7/7- 7a 3'7573 flaah-marefte.4al'
Email
1
Phone Number
Cftsf.d ln4D023
JUN 2 0 2024
es en4+verUtrr r.
PRTOR l-lCENSURE
Has the owner or operator of the Pro
technician license or permit?
lease lis the in tio
E
State/Municipalitv .ic./Cert./Reg. #
eld a body art
below. Attac additional s if necessary.
S s (Active/Ex
E Yes
trNo
State,Municipality Lic./Cert./Reg. #Status (Active,iExpired/Sus pended)
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or Permit?
tfyet, pleot, list the information belov'. Attach additional pages dnecessary'
! Yes
DNo
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately if paid: Yes-No
EMPI,OYEE INFORMATIoN
Please list and s all Art Technicians tattoo,lercln nlice
Type ofBody Art
Performed
Employee Name
2
Creatcd I D4nA?3
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr
tr
!
D
tr
D
!
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 establishment (net applicrnts only)
A copy of Blood Exposure Conuol Plan
Proof of liability insurance / Workman's Comp' Insurance
Client application and consent forms
First Aid and CPR certilications
Medical Waste Removal Contract
Bloodbome Pathogen Training
Aftercare information and instructions
JUN ? 0 2024
LTH DEPT
Full Name of APPlicant
It is your responsibility to renew your permit at the end of each calendar year'
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. 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 under.stand the obligations and requirements imposed upon a licensed Body Art
Establishment Owneriolerator by thoie 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 thc 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.
Iherebycertis,underpenaltiesandpainsofPerjury,thattothebestofmyknowledgethe
information provided on this-application is compiete and accurate and in no way misrepresented'
,:.
D
3
Signature
clealcd 1D412023
THE COMMONWEAL MASSACHUSETTS
TOWNOFYARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Csrtiry that Noah Moretz
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,
Sections 51, ofthe General Laws, ani amendments ther&o] and is subject to the provisions ofihe LaiNs ofthe
Commonweahh of Massachusetts relating thereto, and upon such terms and coiditions, 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.
Hillard Boskea, M.D., Chnirmnn
Maru Crnis, Vice Chnirmnn ChnrlesHolioav, GirkEic Weston
Laurance Venezia, DVM
Jarua* 1.2024. BOARD OF HEALTH:
(date)
James G.
Health
PERMIT NUMBER: #24-033