HomeMy WebLinkAboutDwight CookeTHE COMMO ALTH OF MASSACHUSETTS
TOWN OP YARJT,IOUTH
BOARD OF HEALTH
PERMIT NUMBER: p 24-036 FEE: $55.00/ Technician
This is to Certifo ttrat Dwieht Cooke
at SoiIt 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 Healrh, by Chapter 140,
Sections 51, ofrhe,General I aws, and amendments thenitol and is subject ro the provisions ofihe Lai*,s ofttrdCommonwealth ofMassachusetts relating thereto, and upon such terms and coirditions, and to the rules and
regulations in regar-d, to-th-e carryinB on of the occupation so Iicensed as adopted by the Board of Health, and
expires December 3 I , 2024 unless sooner revoked.
2024 BOARD OF HEALTH:Hillard Bosktv, M.D., Clmirmnn
Marv Crais. Vice Chairman ClnrlesHolil'av, CTtrkEic Weston
Laurance Venezia, DVM
(date)
Jarnes G. G
Direcl rh
Ianrr arv
TOWN OF YARMOUTH
1 146 ROUTE 28, SOUTH YARMOUTI{, MASSACHUSETTS 0266{.24451
Tehphone (50t) 39V2231,qL 1241
Fax (50t) 76&3472
ENew fl ncncwa ApplicationFods): 3160/Fecilitv $55/T
Board of
Hcrlth
Hc.ltt
Division
Tvoc of Aoolicrtbn
Typ{s) of Body Art D Tattoo Facility
a Piercing FacilitY
ESTAELISHMENT IIYFORMATTON
f fanoofecmicim tr APPrertice
c PiercingTr-hician
0uft{8s
Name &
b
Stde
[pcof orncnhlp: tr SoleProprietor tr Corporation tr PdtDership
If establisheffi is orrned by a corpor*ion, partrership, or other combination of individtuls, plcase
attach tho namc, title, tor ID#, ad hone addrcss of all owners.
Ertrbtrtncat Osncr'r / TecDddur Neme:
L M
Middle Initial
Z
Date Tax
luN 2 0 ?0?4
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aNe
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D
PE
PRIOR LICENSURE
Hes the owner or operator of the proposed esteblishment ever h
technicien license or permit?
Ifyes, please list the information below. Attach additional pages dnecessary
es
o
State/lvlunicipality Lic./Cert.,/Reg. #Status (Active/Expired/Suspended)
n
S
SfiN E L.2 -00
Lic./Cert./Reg. #Status (Active/Expired/Suspended)
E Yes
trNo
Has the owner or operrtor ofthe proposed establishment ever held a body art
egtablishment license or Permit?
tf yrt, ptt*, list the information below. Attach additional pages if necessary'
Lic./Cert./Reg. #Surtus (Active/Expired/Suspended)
Statefivlunicipality Lic./Cert./Reg. #Status (Active/Expired/S uspended)
Town of Yarmouth trxes and liens must bc paid prior to renewll or issuance of your p€rmits.
Please check appropriarely if paid: Yes- No
EMPLOYEE INFORJUATION
nticePlease list and c all Art Technicians attoo,ercr
Type ofBody Art
Performed
Employee Name
2
cfti!:.d lD4D0
luN 2 0 2024
Statefvlunicipality
Requircments 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 n)
Detailed floor and operation plans of proposed body art establishmenl (new applicants only)D
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JUN 2 o 2024
HEALTH DEPT
Applicrnt Strteme[t of Consent
I understand thet this permit is valid only in the Town of Yarmouth and expircs at the end of
the calendrr year in wiich it wes issued. I also undentand that any notice to be mailed to me by
the Town of iarmouth Bosrd of Heelth will be meiled to the eddress indiclted otr this
application.
I heve neceived a copy ofthe Yarmouth Boerd of Heelth Body Art Reguletions. I heve reed
ond uDdeBtrtrd tbe obligetions end requirrments imposed upon a licenscd Body Art
Esteblishment Owner/Operetor by those reguletions. I also egree to comply with all of the
reguletion requircmentsipecified in the Yarmouth Borrd bf Health Body Art Regulations
while pncticing in the Town of Yermouth.
I furthcr undentrnd thet it is my responsibility to ensure that individual Body Art Technicians
working in this establishment have I current valid Yarmouth Board of Health Body Art
Technician License and comply with all rpplicrble health, safety, srnitstion' sterilization, and
work prectices reguletions es specified in the Yrrmouth Board of Heelth Body Art
Regulations.
I hercby certi$, under penrltics rnd prim of perjury, that to the best of my knowledge the
ilfomrtion pnovided on thir rpplicetion is complete end rccurrte rrd in no wey misrepresented.
0wiqhr CooKe
['ull Nr#e of Appliernt
It is your responsibility to renew your pcrmit rt the end of each calendar yeer.
3
c
A copy of Blood Exposure Control Plan
Proof of liability insurance / Workman's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Mdical Waste Removal Contact
Bloodbome Pathogen Training
Aftercare information and instructions
Crcded ll24D0