HomeMy WebLinkAboutTory DestrompTH NWEALTH OF MASSACHUSE
TOWN OF YAR]\{OUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-037 FEE: 355.00/ Technician
This is to Certiry $at Torv Destrcmp
at Soilt Milk
C
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 theretol and is subiect to the provisions ofihe Laws ofthe
Commonwealth ofMassachusetts relating thereto. and upon such terins and coirditions, and ro the rules andregulations in regar-d. to-the carrying on ofthe occupationso licensed as adopted bythe iloard ofHealth, and
expires December 31, 2024 unless sooner revoked
Januarv .2024.BOARD OF HEALTH:
(date)
Hillard Boslcv, M.D., Chairman
l)lary Cra1g, Vice Chnirmnn Chnrles
t1ol70au, Llerk
E'ic Weslon
Laurance Venezin, DVM
James G
Director of th
TO WN OF YARMOUTH
I 146 ROUTE 28, SOUTH YAR,MOUTH, MASSACHUSETTS 02654'24451
t241
Board of
Hc.th
Hcrltr
DivirionTelephone (50t) 39&2231 , ott
Fax (50t) 7@3472
Tvpo of Anolhrlion
E New F R€npwat Applicatisa Fe{s): $160 / Ieci[tv $55 /
Typ{s) of Body Art tr Tattoo Facility
a Piercing FacilitY
ESTABLISHI.IENT IIYFON.MATION
OUft ,28
Name &
b
State
Ilpcof orncnhlp: tr SoleProprieor tr CoT poration tr Prmership
$establish€d is ounred by a corpor*ion' putDcsship' or other combirstion of individuals' plcase
attaoh the namc, title, ta:r ID#, and homc adfuss of all owners'
fttrttrtnotrt Owncr'r /Tccbddrur Naoc:
rn L
Fint tfft Middle Initial
5
f fattoofectoicim o APPrcntice
o Piercing Tecbnician
s
Tax
State
0q
zip
)
(!
I Z
1
6lt!c;i31.l\? t-=t9
JUN 2 0 2024
HEAITH DEPI
- 531-+t 5
&rd lDlll
L-::;ErVED
PRIOR LICENSURE
Hrs the owrer or operrtor of the propo3ed
!g@!@ license or Permit?
If yes, please list the information below. Attach additional pages if necessary.
establishment
,';L| '., l) ?ll14
held e bodv ert
H E,T. LTFi DdPI 9Qes
trNo
State/lvlunicipali$ Lic./Cert./Reg. #
pality Lic.lCert.lReg.#
Status (Active/Expired/Suspended)
qP-t4
Status (Active/ExPired/Suspended)
Eas the owncr or operrtor of the proposed establishment ever held a body art
establishment license or Permit?tfyrWtt* titt the infornation below. Attach additional pages if necessary'
E Yes
trNo
State/Ir4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
StateMunicipdity Lic./Cert./Reg. #Status (ActivelExpired/Suspended)
Town of Yarmouth trxes and liens must be paid prior to renewal or issuance of your permits'
Please check appropriately if paid: Yes-No
EMPLOYEE INFORIVIATION nlicePlease list and s all Art Technicians e
Type ofBody Art
PerformedEmployee Name
2 C*'dct \D4n0
tr
I
E
E
!
E
D
L
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, p.lssport, or military-issued Io)
Detailed floor and operation plans of proposed body art establishment (new epplicants only)
bJ-9.:=lJ'\YL=l,!,
JUN 2 0 2024
HEALTH DEPI
Applicant Statment of Consent
I understand thet this permit is valid only in the Town of Yarmouth and expires at the end of
the c4endar year in which it wcs bsued. I also understand that any notice to bc mailed to me by
the Town of Yermouth Boerd of Herlth will be mgiled to the eddress indiceted on this
application.
I hevc rcceived r copy ofthe Yrrmouth Boerd of Heetth Body Art Reguletions. I heve rerd
rnd understrnd the obligrtions and requiremcnts imposed upon a licenscd Body Art
Estrblishment Owner/Operator by those reguletions. I also agree to comply with all of the
rcguletion requircments specified in the Yermoutb Board bf Herlth Body Art Reguletions
while pncticing in the Town of Yrrmouth.
I furt1cr underrtrnd that 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 applicrble health, safety, sanitation, sterilization, and
work prectices reguletions es specified in the Yermouth Boerd of Health Body Art
Regulations.
I hereby certify, under peneltics rnd prhs of perjury, thet to the best of my knowledge the
informrtion provided on this apphcation is complete end eccurate and in no way misreprtsented.
0r ( Slrt m
Full N Applicant
7 2-
Date
It is your responsibility to renew your permit et the end of each calendar year'
A copy of Blood Exposure Connol Plan
Proof of liability insurance / Worlman's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Medical Waste Removal Contract
Bloodbome Pathogen Training
Aftercare information and instructions
(?
3
cte4.d l/uDo