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Home My WebLink AboutDennis DuranJames G. G Direclor THE COMMONWEALTH OF MASSACHUSETTS TOWNOFYARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-038 FEE: $55.00i Technician This is to Certifo that Dennis Duran at Spilt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in conformity with the authonty granted to the Board of Health, by Chapter 140, Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe [-aws ofthe Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board ofHealth, and expires December 31, 2024 unless sooner revoked. Hillnrd Boskev, M.D., Chairman Maru Crnis. Vice Chairmm Charles Holi,nu, Airk Eic Weston Laurunce Venezia, DVM January 1,2024, BOARD OF HEALTH: (date) rh Tvoe of Aoolicetion E New Typ{s) of Body Art D Tattoo Facility tr Piercing FacilitY ESTAELISHMENT INFON,MATTON TOWN OF YARMOUTH I I45 ROUTE 2t, SOUTII YAR,MOUTI{, MASSACHUSETTS 0266G24451 Telcphone (50t) 39V2231, qL 1241 Fax (50t) 7@3472 F R€oewat ApplicationFods):$160/Frciltty $55/ Boqi, of Hc.fth Hcrltt Divigion y' f*toofecUician E Apprcr$ic€ tr Piercing Technician 0uft ,28S Name & b State Ilpc of orncnUp: tr Sole Proprietor tr CorpoT aion n Pamership If estsblilffi is oumed by a corporation, putncrship, or other combination of individuals, plcase attach thp name, title, tax ID#, ad home ad&ess of all oumers. E trb[atncut Owncr'r /IecblHru Nare: FirBt I^ast Middle Initial Tax # th tql Lb+' 1 ,l ,|UN ? 0 ?024 HEAITH D I lr:I/ED-=:_-=l Phone f tq-q T V Ctad ll21h PRIOR LICENSURE Hrs the owrer or opentor of the proposed establishment 199@!9@ license or Permit? pYes DNo Iltytease list the information below. Attach additional pages if necessary. JUN 2 0 2024 held a body art H EALTH DEPI Lo)tr State/tlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State/lr,I Lic Cert./Reg. #Status (Active/Expired/Suspended) E Yes trNo Hes the owncr or operitor ofthe proposed egtablishment ever held a body art egtrblfuhm ent license or Permit? Ifyes, ptease list the information below. Attach additional pages if necessary' State/Ivlunicipality Lic./Cert./Reg. #Status (ActivelExpired/Suspended) StateA,Iunicipality Lic./Cert./Reg. #Status (ActivelExpired/S uspended) Town of Yermouth trlGs and liens Eust be paid prior to rtnewal or issuance of your permits' Please check appropriately if paid: Yes.-No EMPLOYEE INFORMATTON enlicePlease list and s all B Art Technicians efcti Type ofBody Art Performed Employee Name cr.aret I n4D0 I 2 Requirements for Body Art Establishment 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 operation plans of proposed body art establisbment (new epplicants only) A copy of Blood Exposure Control Plan Proof of liability insrnance / Worknan's Comp. Insurance Client application and consent forms First Aid and CPR certifications Medical Waste Removal Contract Bloodbome Pathogen Training Aftercare information and instructions tuY ? 0 ?024 HEALTH DEP tr E E E E E I tr VTED I Applicant Stet€ment of Consent I undentrnd thrt this permit is valid on[y in the Town of Yermouth and expires at the end of the celender year in wlich it wes isgued. I also understand that any notice to be mriled to me by the Towa of iermouth Board of Heelth will be mailed to the eddress hdicated on this application. I heve received r copy ofthe Yrrmouth Borrd of Heelth Body Art Regulrtions. I heve rerd snd underctrnd the obligetions and requiremcnts imposed upon a licensed Body Art Estebtishment owner/operetor by those reguletions. I also egree to comply with all of the reguletion requircments spccified in the Yarmouth Board of Health Body Art Regulations while practicing in the Town of Yrrmouth. I furtLcr undentrnd thet it is my responsibility to ensure that individual Body Art Technicians working in this estrblfuhment have I curtent valid Yarmouth Board of Health Body Art Technicien License and comply with all applicrble health, safety, srnitation, sterilization' and work prectices reguletions es specified in the Yrrmouth Boerd of Heelth Body Art Regulrtions. I hereby certif, under pcnrlties rnd prirs of perjury, that to the best of my knowledge the infomrtion provided on this eppHcrtion is complete rnd accurate end in no wey misreprtsented. {2en^is Ovr*fi Full Neme of Applieent t.,0 l?.q Date It is your rcsponsibility to renew your permit et the end of each calendlr yeer. 3 I Cr€Ercd I 24120