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Home My WebLink AboutPaul HollandDirector o James G. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YAR]I{OUTH BOARD OF HEALTH PERMIT NUMBER: # 24-040 FEE: $55.00/ Technician This is to Certiry that Rob Mcelorv at Januarv 1.2024. BOARD OF HEALTH: (date) S It 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, oftheGeneral Laws, and amendments thereto, and is subject to the provisions ofihe Laws ofthe Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on ofthe occupationso Iicensed as adopted by the Board ofHealth, and expires December 31, 2024 unless sooner revoked. Hillard Boskv, M.D., Chairmnn Moru Crais. Vice Chairman Chnrles Holi,au. dirkEic Weston Lnurance Venezia, DVM ealth "il'^ o{o TOWN OF YARMOUTH l145 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 0266+24451 Boaril of t{c.lth Hc.lth DivisionTelephone (50t) 39&2231, ext I Fax (50t) 76G3472 Tvoe of Aoolicetion ENew fl nenewat Applicuion Fo{s): $160 / I'rcllttv $55 / T Typ{s) of Body Art: tr Tdtoo Fscility tr Piercing FacilitY ESTABLTSHMEITT INFORIIATTON 0uft '28 Name & Ilpeof orncnhtp: tr SolePropridror tr Co poration tr Prtocrship 11 establfuh€ot is oumed by a corporatioD, putn€rship, or other combindion of individuals, please attach tho name tiOe, tax tO#, ad homc address of all owners. Ert$t$nout Orner's / Tec.Lrld.Dr N.DG: k First Last Middle Initial Tax ID n6 k 0 z+o Z5S7 State z.rp /r*toore*nicim tr Appreirtice tr Piercing Technician s * no n 1 . -: r_=- g =.9_/ ;uN t U ?024 HEALTH DEPI 3 - qa bLl Crrr&d laillD ,l PRIOR LICENSURE Has the owner or operetor of the proposed estrblishment !ggbg[@ license or permit? If yes, please list the information below. Attach additional pages if necessary. Q4te" !No State,{r4unicipality Lic./Cert.,&eg. # r) Statefiv1 cl ty Lic./Cert./Reg. # Satus (Active/Expired/Suspended) 025-0 Status (Activ ired/Suspended) Hrs the owner or operetor ofthe proposed establishment ever held a body art estrblishm ent license or Permit? Ifyes, please list the information below. Atlach additional pages if necessary' State/Irifunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State,Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) Town of Yermouth trles and liens must be paid prior to renewal or issuance of your p€rmits. Please check appropriately if paid:Yes No EMPLOYEE INFORMATION nticePlease list ond s all Art Technicians attoo,terct Type ofBody Art Performed Employee Name 2 Creat d L24,20 ".-= :_ _:_ : =i JUI\ 2 U 2024 E Yes trNo D Requirements for Body Art Estrblishment Permit Submit the following to complete your application: A copy ofowner's valid identification card with picture (stare-issued license, passport, or military-issued to) Detaited fl,oor and oper'ation plans of proposed body art establishmenl (new epplicents only) A copy of Blood Exposure Conrol Plan Proof of liability insurance / Workrnan's Comp. Insurance Client application and consent forms First Aid and CPR certificatiors Medical Waste Removal Contract Bloodbome Pathogen Training Aftercare information and instn'rctions n L E tr E E !,trlir ; ti ?024 H EALTH DEPT! Applicant Strt ment of Consent I undentand thrt this permit is valid only in the Town of Yarmouth and expires at the end of the c4ender year in wlich it wes issued. I also undemtand that any notice to be mailed to me by the Town of iermouth Boerd of Herlth will be mailed to the eddress indicated on this application. I heve rcccived I copy of the Yrrmouth Borrd of Hedth Body Art Reguletions. I heve rcrd md underrtrId the obligrtionc end rcquincments imp6ed uPon e licenscd Body Art Esteblishmcnt Owner/Operator by those reguletions. I elso egree to comply with all of the rcguhtion rcquirements spocified in the Yrrmouth Board of llealth Body Art Regulrtions while pncticing in the Town of Yrrmouth. I furthcr under:sr"nd thet it fu my responsibility to ensure that indMdual Body Art Technicians working in this estrblirhment have a current valid Yarmouth Board of Health Body Art Technicirn License end comply witb all applicable health, safety, sanitation, sterilization, and work prrctices rogulrtions es specified in the Yermouth Board of Hcalth Body Art Regulrtious. I herrby certify, under peneltiel rnd peins of perjurT, thrt to the best of my knowledge the infomrtioa provided on this eppHcetion is complete end lccurate and in no way misrepresented. {Loa MLLV RDY of b/ta L4 Date It is your reeponsibility to renew your permit rt the end ofeach calendar yeer. 3 Creqed U24/20 James G. G Direclor THE MMONWEALTH OF MASSACHUSETTS TOWII OFYARMOUTH BOARD OF HEALTH PERMIT NUMBER:#24-041 FEE: $55.00/ Technician This is to Certifu Paul H lland 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 authority granted to the Board of Health, by Chapter 140, Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on ofthe occupation so licensed as adopted by the Board ofHealth. and expires December 3l . 2024 unless sooner revoked. Januarv 1.2024. BOARD OF HEALTH:Hillard Boskcv, M.D., Chairnnn Maru Crais. Vice Chnirman Chnrles Holi,av, Clirk E"ic Weston Lnurance Venezia, DVM (date) ealth TOWN OF YARMOUTH Boad of Heahh Hcaltt Divigionl146 ROUTE2& SOUTH YARMOUTI{, Telephore (50E) 39&2231, ext Fax (50t) 76G3472 Tvoe of Aoolkrtbn ENew F REo€{Iat Application Fe(s): 3160 / Feclltty $55 / TcchnhLn $55 / Apprutice f fanoofecmicim tr APPrentice tr Piercing Technician s q8 0uft18 Bu$oess Name & EctrbtfrDctrt Olvner'c / Tes.tddrDi N.me: tt)t+xl Itlt't SETTS 02654-24451 Typ{s) of Body Art tr Tattm Fscility tr Piercing FacilitY ESTAf,IJSNMENT IiIFORTI ATK)N Typc of owncnhlp: tr Sole Proprietor tr Corporation tr Prtncrship If establishent is ou,led by a corporstion, putnership, or other combinrtion of hdividtuls' plcase *ach the name title; tsx ID#, md home address of all owners' JUi\ 2 U 2024 HEALTH DEPT, r24F: lnst3rn Middle hitialFkst ax only) 0r k State st) 1 cit,dl.2$) ,t ,tUlt 2 U Z0Z4 PRIOR LICENSURE Hes the owDer or operetor of the proposed esteblishnen Ep!4!ig license or permit? If yes, please list the information below. Attach additional pages if necessary' FesnNo State/lvlunicipality Lic./Cert./Reg. # L State/M pality Lic.# Status (Active/Expired/Suspended) fr4b5T0 Has the owner or opentor of the proposed establishment ever held r body art egtrblishment license or Permit? tJyn, pt"*e tttt the information below. Attach additional pages if necessary' Status (Active/Expired/Suspended) L] YCS trNo Statellvlunicipdity Lic./Cert./Reg. #Stntus (Active/Expired/Suspended) StateMunicipality Lic./Cert./Reg. #Status (Active/Expired/S uspended) Town of Yermouth trxes and liem must be paid prior to rtnewal or igsuance of your permits' Please check appropriately if paid: Yes No EMPLOYEE INFORIUATION Please list and s,all Art Technicians afioo erct tce Type ofBody Art PerformedEmployee Name 2 Crcar..d ln4D0 D E E ! D E D tr Requircments for Body Art Estrblishment Permit Submit the following to complete your application: I A copy ofowner's valid identification card with- picture (statd-issued license, passport, or military-issued n) Detailed fl,oor and operation plans of proposed body art establishFenl (new rpplicmfi only) A copy of Blood Exposure Contol Plan Proof of liability insurance / Workman's Comp' Insurance Client application and consent forms First Aid and CPR certifications Medical Waste Removal Contract Bloodbome Parhogen Training Aftercare information and instn rctions llan/ FuIl Nane ofApplieent 0/u/zr D ,tUlr 2 tl 2024 HEALTH DEPT Applicant Strtement of Consent I undentand th.t this permit is valid only in the Town of Yarmouth and expires at the end of the celender year in wiich it wss issued. I also understand that rny notice to be mailed to me by the Towu of iarmouth Board of Heelth will be mailed to the rddre$ indicated on this application. I have reccived e copy of the Yarmouth Boerd of Heelth Body Art Reguletions. I heve reed rDd undeBtud the obligationr snd rcquircment! imposed upon a licensed Body Art Estebtishment owner/operator by thoie reguletions. I also egrec to comply with ell of the reguletion requirements specified in the Yarmouth Borrd bf Hedth Body Art Reguletions while pncticing in the Town of Yermouth. I further underctrnd thrt it is my responsibility to ensure that hdividual Body Art Technicians working in this establirhment have e current valid Yermouth Board of Health Body Art Technicirn License and comply with all applicable hcrlth, slfety, sanitation, sterilization' and work prectices reguhtions es specified in the Yrrmouth Board of Health Body Art Regulations. I hereby certify, under pendties and peins of periury, thot to the best of my knowledgc the informrtion p-riaa on tnis appucation is complete and eccurate rnd in no wey misrepresented' Drte ? It is your rcsponsibility to renew your permit et the end of each calendar year' L::.; i!vE Cr€aed t/24l20