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Home My WebLink AboutSkylard JamesECO o TOWNOFYARMOUTH BOARD OF HEALTH Skylard James TH OF MASSACH SETTS PERMIT NUMBER: # 24-043 FEE: $55.00/ Technician This is to Certifu that 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 theprovisions 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 Iicensed as adopted by the Board of Health, and expires December 31, 2024 unless sooner revoked. Hillnrd Boskeu, M.D., Chairmnn Maru Crais, Vice Chairman ChnrlesHolfiav, Clerk Eic Weston Laurance Venezia, DVM Jatlr,:arv 1.2024. BOARD OF HEALTH: (date) James G. Gardiner Director of Health TOWN OF YARMOUTH l l,r5 ROUTE 2& SO{JTH YARMOUTH, MASSACHUSETTS 02654-24451 Tclcphone (50E) 39V2231,ert" 1241 Boord of Hcdth Hctldt Division Fax (50t) 760-34't2 Tvne of Anollcethn E New fl Reoewat Applicatim Fo(s): 3160 / Frdlitv $lt5 / Typ{s) of Body Art n Tattoo Facility tr Pie,tcing FacilitY ESTAf, LISHMENT IIINORMATTON 0 U/< ,28s B Name & Typoof orncnhlp: tr Solehoprietor tr Corporation tr Pdtnership If establisho€nt is ovmed by a corporation' partneship, or other combination of individuals' plcase attach rhe name, title, tax IO#, ad homc ad&ess of all o'*mers' Ertrbfirtncut Ownor's / tccDlHur Nrmc: -t /4 t"ast Middle Initial zlx eDly) [0n sl-1- uv(r lfattoofecUician D Apprentice tr Piercing Tecbniciar z.rp a 1 E=-==lvED ,ruN 2 0 2024 TH T ?_0 -- 7Ez( C\td ll2lD ! -- .i=_ : =i/ JUN 2 iJ 2024 PRIOR LICENSURE Hrs the owtrer or operrtor of the proposed establishment lechnicirn Ucense or permit? If yes, please list the information below. Attach additional pages ifnecessary. es trNo State/tlunicipality Lic./Cert./Reg. # 2 Lic./Cert./Reg. # Status (Active/Expired/Suspended) 0L SI S Status (Acti uspended) Hes the owner or operrtor ofthe proposed estrblishment ever held a body art estrblbhment license or Permit? Ifyes, please list the information below. Attach additional pages if necessary. E Yes CNo State/trIunicipality Lic./Cert./Reg. #Stntus (Active/Expired/Suspended) StateMunicipality Lic./Cert./Reg. #Status (ActivelExpircd/Suspended) Town of Yermouth tges and liens must be paid prior to rtnewal or issuance of your permits. Please check appropriately ifpaid: Yes- No EMPI,OYEE INFORMATION Please list and all Art TecJmicians nticeIrct Type ofBody Art Performed Employee Name 2 crcrrcd I 24120 x Requirements for Body Art Esteblishment Pernit Submit the following to complete your application: A copy of owner's valid identification card with picture (state-issued licerse, passport, or military-issued Io) Detailecl floor ^nd operation plans of proposed body at establishmeal (new epplicents only) A copy of Blood Exposure Connol Plan Proof of liability insurance / Worlooan's Comp. Insurance Client application and consent forms First Aid and CPR certifications Medical Waste Removal Contract Bloodbome Pathogen Training Aftercare information and instructions Full eme of Applicent (/() te It is your responsibility to renew your pcrmit et the end ofeach calender year. D L D E E E E g iit9 Applicant Strt€ment of Consent I urdentend thrt this permit is valid only in the Town of Yarmouth and expires at the end of the crlendrr yeer in which it wgs issued. I also urderstrnd that any notice to be mailcd to me by the Town of iemouth Board of Heelth will be mailed to the rddress itrdicrted on this application. I have rcceived r copy of the Yrrmouth Borrd of Hedth Body Art RegUletions. I have reed cnd urderrtrtrd the obligrtions rnd rrq[iremon8 imposed upon e licenrcd Body Art Estrblishment Owner/Opcrator by those regulrtions. I also egree to comply with all of the rcgulrtion requirementsipccified in the Yrrmouth Board bf Heeltt Body Art Regulrtions while pncticing in the Town of Yrnnouth. Jnn I firrther undentrnd thrt it is my responsibility to ensure that individual Body Art Technicians working in this ectablishment hrve . current vthd Yarmouth Board of Health Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work prectices reguletions rs specified in the Yrrnouth Board of Health Body Art Regulations. I heneby certify, under penrltier rnd prins of pcrjury, thrt to the best of my knowledge the informetion providcd on ttis epplicrtion is complete end accurate end in no way misreprceented. 3 cred.d I24l20 JUN 2 0 2024 HEALTH DEPT.