HomeMy WebLinkAboutRaymond SchmoldtETA
PERMIT NUMBER: # 24-042
TOWNOFYARMOUTH
BOARD OF HEALTH
Raymond Schmoldt
FEE: $55.00/ Technician
that
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 of Massachusetts 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 31, 2024 unless sooner revoked.
Hillard Boskcv, M.D., Chairman
Maru Crais, Vice Chairman Charles
Holzi,av, Cfirk
Eic Weston
Laurance Venezia, DVM
Jamtary 1,2024, BOARD OF HEALTH:
(date)
James G.
This is to Certifo
at Soilt Milk
JUN 2 U 2024
ET OWN M OUTH
I 146 ROUTE 28, SOI..TTH YARMOUTH, MASSACHUSETTS 0266+2445I
Telephone (50E) 39V2231,qL l24l
Fax (50t) 76&3472
Boaril of
Hc.lth
Hr.lth
DivisiDn
Tvoe of Aoolicrtbn
E New fl neaewaf Applicatim Fods): $160 /frciltty $55 / Tcchnicirn $55 / Apprutlce
s 0
B Name &
Typc of orncnhtp: tr Sole Proprietor tr Corporation tr PatDcrship
If cstablishd is o*ned by a corporation' pumship, or other combilation of individuals' plcase
*tach the name, title; tax ID#, ard homc ad&ess of all owners'
E trttrfimat Owndr / TccllHeu Nroc:
0
Typ{O of Body Art n Tattoo Facilily
tr Piercing FacilitY
ESTAELISIIMEI{T II{NOR}IATION
,,d fattoofecmician D APPrentice
tr Piercing Technician
uft '28
Middle Initial
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Last
luN 2 0 2024
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PRIOR LICENSIJR.E
Hes the owtrer or operetor of the propored egtrblishm
!gg@ig@ license or pcrmit?
If yes, please list the information below. Attach additional pages if necessary
.fut
trNo
State/tlunicipality Lic./Cert./Reg. #
S cipatity Lic./Cert./Reg. #
Status (Active/Expired/Suspended)
000
Status (Active/Expired/Suspended)
Hrs the owner or operator ofthe proposed estrblishment ever held a body art
establishment license or Permit?
tf yetpteate list the information below. Attach additional pages if necessary'
E Yes
trNo
State/lv{unicipdity Lic./Cert./Reg. #Stntus (Active/Expired/Suspended)
State&Iunicipality Lic./Cert./Reg. #Status (Active/Expire.d/S uspended)
Please check approprixely ifpaid: Yes---
EMPLOYEE INFORMATION
erct nlicePlease list and s.all Art Technicians
Type ofBody Art
PerformedEmployee Name
)
CrcdcnlD4n0
rr
Town of Yarmouth trxes and liens must be paid prior to rtnewd or isguance of your pemits.
No
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Requirements for Body Art Esteblishment Permit
Submit the following to complete your application:
A copy ofowner's valid identification card with picture
(state-issued licerse, passport, or military-issued n)
Detailed fl,oor and operation plars of proposed body art establishment (new epplicenfi only)
A copy of Blood Exposure Contol Plan
Proof of liability insurance / Worknan's Comp. Insurance
Client application and consent forms
First Aid and CPR certifications
Medical Waste Removal Contact
Bloodbome Pathogen Training
A-ftercare information and instuctions
0
It is your responsibitity to renew your permit rt the end ofeach calendar yeer'
JUI\ 2 U 2024
HEALTH DEPT
Applicant Stettment of Consent
I understend thet this permit is valid only in the Town of Yarmouth and expircs at the end of
the crlendrr yerr in which it wes issued. I also understand that rny notice to be mailed to me by
the Town of iemouth Board of Heelth will be mailed to the rddress irdicsted on this
application.
e-u
I have received e copy of the Yrrmouth Borrd of Health Body Art Reguletions. I heve rerd
cnd understrnd the obligrtions rnd requircments imposcd upon a licensed Body Art
Esteblishment Owner/Operrtor by those regulations. I elso egree to comply with all of the
regulation rcquirements specified in the Yarmouth Board of Health Body Art Regulrtions
while pncticing in the Town of Yrrmouth.
I further understend that it is my responsibility to ensure that individual Body Art Tcchnicians
working in this est blfuhment hlve a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, sanitation' sterilization' and
work prectices reguletions es specified in the Yrrmouth Board of Health Body Art
Reguletions.
I hereby certify, under pcn.ltica rnd priru of perjury, thet to tho best of my krowledge the
informetion pr.ovided on this epplicrtion ir complete rnd lccurrte rnd in no wey misreprteented.
Ra Wl0n
Full N of Applieent
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