HomeMy WebLinkAboutDale SchmittCO NWEALTH F MASSA U ETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Techniclan
This is to Certifi that Dale Schmitt
at SDilr 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 bythe Board ofHealth, and
expires December 31, 2024 unless sooner revoked.
January 1,2024, BOARD OF HEALTH:Hillard Boskev, M.D., Chairnmn
Maru Craio. Vice Chairman Clnrles
Holi,av, Clirk
Eic Weston
Laurance Venezia, DVM
(date)
James G
PERMIT NUMBER: # 24-045
i.l-
TOW N OF YARMOUTH
I146 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS 0265+2445 I
Telephone (508) 398-2231, ext. l24l
Fax (508) 760-3472
D New fl Renewal Applicarion Fee(s): $160 / Fasility $55 / Techn
Health
Division
Type(s) ofBody Art: trTattoo Facility
D Piercing FacilitY
ESTABLISHMENT INFORMATION
,dTattooTechnician tr APPrentice
tr Piercing Technician
B Name &
(?
lty State
Type ofownership: il Sole Proprietor tr Corporation
If establishment is ovned by a corporatioq partnership, or other combination of individuals, please
attach the name, title, tax ID#, and home address of all owners'
Estoblilhment Owner's / Techniciru Name:
First Last Middle Initial
5 only)ofB Gender Tax ID
Le
4zt
State zip
lnhduh l0
q8 Ko uK 18
zip
tr Prtr€rship
C
.t0rn
umberN Email Address
1
HEAT
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Board of
Healtlt
Tvne of Aoolication
S
JUN 2 0 2024
Crcatld lD4D0T
JUN ( u ?024
H ifr,r
s -::-
PRIOR, LICENSIJRE
Hes the owner or operator of the proposed esteblishment ever
@@!!9g license or Permit?
ffiilr^, list the information below. Attach additional pages if necessary'
CS
No
State/I,lunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
ft
Hestheowneroroperatoroftheproposedestrblishmenteverheldabodyart
est&blishment license or Permit?
Mitt the information below. Attach additiohal pages if necessary'
Z-*KL QT
Lic./Cert./Reg. #Status (Active/Expired/Suspended)
E Yes
trNo
State/]vluoicipality Lic./Cert./Reg. #-ratus(ActivelExpired/S uspended)
Lic./Cert./Reg.#Status (Active/Expired/S uspended)
Town of yermouth tares and liens must be paid prior to rene\Ysl or issuance ofyour permits'
Please check appropriately ifpaid: Yes- No
EMPLOYEE INFORJUATION nlicePlease list and all Art Technicians attoo rct
Type ofBody Art
PerformedEmployee Name
)
Crcatcd I 2420
t^:
Requirements for Body Art Esteblishment Permit
Submit the following to complete yow application:
A copy of owner's valid identification card with picture
(state-issued license, passport, or military-issued to)
Detailed ftoor and operation plans of proposed body art establishmenl (new applicants 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 cprtifications
Medical Waste Removal Contract
Bloodbome Pathogen Training
Aftercare information and instructions
E
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I
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Applicant Statement of Consent
I underrtend thrt this.permit is valid only in the Town of Yarmouth and expires at the end of
the celender ycer in wiich it wrs issued. I also understand that any notice to bc m"iled to me by
the Town of iemouth Board of Heelth will be mailed to the rddr$s indicrted on this
epplication.
I have received a copy ofthe Yarmouth Borrd of Health Body Art Reguletions. I have reed
rnd understrtrd the obligrtions rnd requircments imPosed upon a licensed Body Art
Estrblishment owner/operator by those reguletions, I also egree to comply with all of the
reguletion requirementsipccified in the Yermouth Board bf Health Body Art Reguletions
while pncticing in the Town of Yrrmouth.
I further understand that it is my responsibility to ensure that indMdual Body Art Technicians
working in this establishment have I current valid Yarmouth Board of Health Body Art
Technicien License end compty with all applicablc hedth, srfety, srnitrtion, sterilization, and
work prectices reguletions es specifred in the Yermouth Board of Heslth Body Art
Regulations.
I hereby certify, undcr pcnrltie.trd prim of perjury, thrt to the best of my knowledgc the
infomrtion provided on thig rpplication is complete end rccumte rnd in no way misreprcsented.
0ut- Schm'tif
Full Neme of Applicent
L
It is your rerponsibility to renew your permit at the end of each calendar year.
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3
HEALTH DEP
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I
Crened I2410
,juN 2 0 2024