HomeMy WebLinkAboutNicholas StrongTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OT'YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #24-039 FEE: $55.00/ Technician
This is to Certifu that Nicholas Strong
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACT]CE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51. oftheGeneral Laws, and amendments theretoland is subject to the provisions ofihe Laws oftheCommonwealth ofMassachusetts relating thereto, and upon such terins and coirditions, and to the rules and
regulations in regard to the carrying on olthe occupation so licensed as adopted by the Board ofHealth, and
expires December 31,2024 unless sooner revoked.
Jantary 1,2024, BOARD OF HEALTH:
(date)
Hillnrd Boskev, M.D., Clnirnan
Maru Craip, Vice Chairnmn Chnrles
Holionv, Cfirk
E'ic Weston
Laurnnce Venezin, DVM
lner
ealth
James G.
TOWN O F YARMOUTH
1145 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS 02664"2445 I
Telephone (50t) 39&2231, ext 1241
Fax (50t) 76&,3472
Bosd of
Hcatlh
Hcrtth
Divigion
Tvoo of Amlhrrtor
ENsw F REncwal APPlicatioo Fo(s): 3160 / FrcllttY $55 / T
y'fanoofecmicim tr APPrcntice
n Piercing Technician
UK l8
Typ{s) of Body Art D Tattoo Facility
tr Piercing FacilitY
ESTAELISHMENT NF'ORI}TATION
Name &
0 S
First tnst
Dale
,l l-
il
s a
(p
Middle Initial
534 -tw
Typc of orncnhip: tr Sole hoprieor tr Corrporation x Prtncrship
restablfuh€nt is oumed by a corporatioD, pCtcrship' or other combinatior of individuals' plcase
"rtul tt, ,r-e tiOe, tax ID#, and hooe ad&ess of all owneis'
Ertrtt6nmt Owacr's /Te$Dfdrlt NrDc:
L Tax
State
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luN 2 0 2024
PN.ION, LICENSTJRE
H"r th" o*o"t or operetor of the proposed etrblishment
lgg@jgjg license or Permit?
Ifyes, please list the informatio n below. Attach additional pages if necessary'
State/lvlunicipalitY Lic./Cert./Reg. #Status (Acti
n 0
es
trNo
ve/Expired/Suspended)
clvd
Status (activelExpired/S uspended)
Status (
tatus (Active/Expired/Suspended)
rrnewal or issuance of your permits'
attoo,erct entice
I
Ers the owner or opentor of the proposed establishment ever held a body art
establbhment license or Permit?
Mit, the informalion below. Attach additional pages if necessary'
StateA,tunicipality
State/lvlunicipaIitY
EMPLOYEE INFORMATIQN
ty Lic./Cert./Reg.
Lic./Cert./Reg' #
Lic./Cert./Reg.#
all Art Technicians
S
Town of Yarmouth tares and tiens must be paid prior to
ilease check appropriately if paid: Yes-.=- No
Please list and 1
Type ofBodY Art
PerformedEmployee Name
2 Creatcd I /24,20
E Yes
flNo
Lrr
Requirements for Body Art Esteblishment Permit
Submit the following to complete yow 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 establishment (new epplicenb only)
D
D
!
E
tr
E
E
!
!
A copy of Blood Exposure Control Plan
Proof of liability insurance / Worknan's Comp. Insurance
Client application and consent forms
Fint Aid and CPR certifications
Medical Waste Rernoval Contract
Bloodbome Pathogen Training
Aftercare information and instructions
Appticant Statement of Consent
I understand thrt this permit is valid onty in the Town of Yermouth and expires at the end of
it. .*oaer y""r in wf,ich it wes igsued. I ako understand thrt any notice to bc mailed to me by
the Town of iemouth Board of Heelth will be mailed to the address indicated on this
application.
I have reccived r copy of the Yarmouth Borrd of Health Body Art Reguletions. I have rerd
8nd utrder.stmd the obligrtions rnd requirements imposed upon a licensed Body Art
Estrblishment Owrer/Operator by those regulations. I also egree to comply with all of the
regulation rrquirementsipccified in the Yermouth Board bf Hetlth Body Art Reguletions
while pnc{icing in the Town of Yrrmouth.
I furthcr underrtrnd thet it is my responsibility to ensure that individual Body Art Technicians
working in this estrblishment heve a current valid Yarmouth Boerd of Heelth Body Art
Techniclan License and comply with dl applicablc health, safety, sanitation' sterilization, and
work precticcs rcguletions es specified in thc Yrrmouth Board of Health Body Art
Regulrtions.
I hereby certify, under pcnrltie rnd prhs of perjury, thet to the best of my knowledge the
informrtion provided ou this application is complete end accurate and in no way misreprtsented.
i cK Stron
f,'ull Name of A
Z
te
It is your responsibility to rcnew your permit et the end ofeach calendar yeer.
3
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JUN 2 0 2024
HEAITH DEPI
Cft6,ed l/UDo