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Home My WebLink AboutBrian WoolvertonTHE COMMONWEALTH OF MASSACHUSETTS TOWNOFYARMOUTH BOARD OF HEALTH PERMIT NUMBER: # 24-044 FEE: $55.00/ Technician This is to Certiry ftat Brian Woolverton at SDilt 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 l-aws 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. lanttary 1,2024, BOARD OF HEALTH:Hillard Boskey, M.D., Chairman Marv Crnis. Vice Chnirmnn Clwrles Holipav, Ctbrk Eic Weston Laurance Venezia, DVM (date) )r,-.^Qn L_-/ -Ju r"c. drIi,i"./ Dir€ctor6fHealrh TOWN OF YARMOUTH I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664.24451 Telephone (50E) 398-2231, er<L 1241 Fax(508) 760-3472 Board of He{lth Health Division Tvoe of Aoolication JUN 2 0 2024 D New fl Renewal ApplicationFee(s): $160/Facility $55/T Type(s) ofBody Art D Tattoo Facility tr Piercing Facility ESTABLISHMENT INFORMAIION SnrLt r\il rK q8 0uft '28Busirless Name & Itt Ururnrtvt*h Type of ownenhip: tr Sole Proprietor tr Corporation o Parhenhip If establbhmeot is owned by a corporatioq partnership, or other combination of irulividuals, please attach the name, title, tax ID#, and home address ofall owners. Establirtment Owner's / Technicianr Name: V First Last Middle Initial ,dTattooTechnician tr Apprentice f) Piercing Technician I\I + ILLW3 rzJ t/ ss ll ling ddress (it P State ttgeo w 2 1 Number a Address an crcehd lD D|l luN 202A24 PRIOR LICENSURE Has the owner or operator of the proposed establishment technician liccnse or permit? Ifyes,eas list the information below, Attach additional pages i/necessary. S cipality Lic./Cert./Reg. # art es trNo State/Muni ity Lic.lCert.lReg. # Has the owner or operator ofthe proposed establishment ever held a body art establishment license or permit? If yes, please lisl the information below. Attach additionLll pages ifnecessary. Status (Active/Expired,/Suspended) ! Yes nNo State/l\.{unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State,Municipality Lic.iCert./Reg. # Status (Active/Expired/Suspended) Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: Yes_No EMPLOYEE INFORMATION Please list and s cl all B Art Technicians lattoo,ercl a entice Type ofBody Art Performed Employee Name 2 Cr.ated I D4D021 f-,.-r Nl I nmdurort Status (Active/Expired/Suspended) /+ l I Requirements for Body Art Establishment Permit Submit the following to complete your application: tr A copy ofowner's valid identification card with picture (state-issued license, passport, or military-issued ID) tr Detailed floor end operation plans ofproposed body art establishment (new applicaots only) 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 Medical Waste Removal Contract Bloodbome Pathogen Training Aftercare information and instructions ! ! ! E ! ! LirG;EU\YlEl9 .lUN 2 o 2021 HEALTH DEPT Applicant Statement of Consent I understand that this permit is valid only in the Town of Yarmouth and expires at the end of the calendar year in which it was issued. I also understand that any notice to be mailed to me by the Town of Yarmouth Board of Health will be mailed to the address indicated on this application. I have received a copy ofthe Yarmouth Board of Health Body Art Regulations. I have read and understand the obligations and requirements imposed upon a licensed Body Art Establishment Owner/Operator by those regulations. I also agree to comply with all of the regulation requirements specified in the Yarmouth Board of Health Body Art Regulations while practicing in the Town of Yarmouth. I further understand that it is my responsibility to ensure that individual Body Art Technicians working in this establishment have a current valid Yarmouth Board of Health Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work practices regulations as specified in the Yarmouth Board of Health Body Art Regulations. I hereby certify, under penalties and pains of perjury, that to the best of my knowledge the information provided on this application is complete and accurate and in no way misrepresented. Oria.n Wot/rerfart Full Name of Applicant awlout*ls.o/H/2"/v-Date It is your responsibility to renew your permit at the end ofeach calendar year. 3 S;Aute Cr.ated I n4n023