HomeMy WebLinkAboutBaylen HendersonTHE COMMONWEALTH OF MAS ACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-048 FEE: $55.00/ Technician
This is to Certift that Bavlen Henderson
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth ofMassachusens relating thereto. and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so Iicensed as adopted by the Board of Health, and
expires December 31, 2024 unless sooner revoked
lanuarv 1,2024, BOARD OF HEALTH:Hillard Boskeu, M.D., Chnirmnn
Maru Crais. ViceClnirman Charles
Hohi,av, Cli*
Eric Weston
Laurance Venezin, DVM
(date)
James G.
I Icalth
,l$
TOWN OF YARMOUTH Board of
Healtlt
664-24451 Hcalth
- - .P-lvision1146 ROUTE 28, SOUTH YARMOUTH' MASsAcHUSEr"rA9z
ext. l24lTelephone(508) 39E-2231,
Fax (508) 760-3472
,ru|t ?u2a24 I
HEATT DEP']:HTYoe of Aoolication
fl Renewal
Type(s) ofBody ArI D Tattoo Facitity
D Piercing FacilitY
ESTABLISHMENT INFORMATION
s
B Name &
First Last
ofB
J
Legal
Application Fee(s): $150 / Facility $55 / Technician $55 / Ap
f tanoofecbnician tr APPrentice
tr Piercing Technician
Typc of ownerrhip: tr Sole Proprietol tr Corporation
If es,tablighment is owned by a corporation' parhership, or other combination of individuals, please
*u.h th. *.., titte, tax tp+, and home address of all ownen'
Ertabtirhment Owner'g / Techniclonr Nme:
State
ax ID lishment only)
q6 0uft ,28
(p
zip
D Partoership
Middle Initial
/-tr e 3-t +t/
n
C
cr
tateCity arl (q
1
Address
Cfts8jd lDAn$T
Xt o
E New
#
I
I
JUN / u i).t4
Hai the owner or oPerator of the proposed establishment
!q!p!gi4 license or permit?
If y.es, please list the information
xrt ,.&"t
flNo
Status (Active/ExPired/Sus pended)
fr
Status (Active/Expired/Suspendedl
E Yes
trNo
Status (Active/ExPired/Suspended)
Status (Active/ExP ired/Suspen
renewal or issuance of your permits'
nlice
State/Municipality Lic./Cert./Reg. #
S unrclpality Lic./Cert./Reg. #
Statei\4uniciPalitY Lic./Ce*./Reg. #
State/MunicipalitY Lic.lCert.neg. *
EMPLOYEE INFORMATISN
Please list and s.all B Art Technicians
Town of Yarmouth taxes and liens must be paid prior to
Please check appropriately ifpaid: Yes-- No
c
ded)
attoo.ercl CII
Type ofBodY Art
PerformedEmployee Name
')
crc?,i.d lD4n023
PRIOR I,ICE,NSURE
below. Attoch additional pages ifnecessary'
Has the owner or operator ofthe proposed estsblishment ever held a body art
establishment license or Permit?
Mitt the information below. Attach additional pages if necessary'
tr
!
!
tr
I
!
n
!
!
A copy ofowner's valid identification card with picture
(statd-issued license, passport, or military-issued to)
Detailed floor and operation plans of proposed body art establishment (new applicants only)
A copy of Btood 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
APPlicant Statement of Consent
rdlu
Full \e of Applicant
t0
Date
It is your responsibility to renew your permit at the end of each calendar year'
I undentand that this permit is valid only in the Town of Yarmouth and expires at the end of
in" ""t"oAa. year in wiich it was issued.i also understand that any notice to be mailed to me by
the Town of iarmouth 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 o-bligations and requirements imposed upon a licensed Body Art
Establishmentowner/operatorbvthoseregulations.Ialsoagreetocomplywithallofthe
regulation requirements specified in the Yaimouth Board bf Heatth Body Art Regulations
while practicing in the Town of Yarmouth'
I further understand that it is my rcsponsibitity 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, sterili"ation, and
work practices regulations as specified in the Yrrmouth Board of Health Body Art
Regulations.
I hereby certiry, under penalties and pains of perjury, that to the best of my knowledge the
irio.,outioo piovided on this application is compiete and accurate and in no way misrepresented'
Z
3
,tuN 2 0 2024
t r-S.9,/
EPrIHOHE4I
ature
crcat d ID4/2023
' Requirements for Body Art Establishment Permit
Submit the following to complete your application: