HomeMy WebLinkAboutCosmo MarriTHE COMM NWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF IIEALTH
PERMIT NUMBER: # 24-047 FEE: 555.00/ Technician
This is to Certily that Cosmo Marri
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,
lections 51, ofrhe,General Laws, and amendments thereto, and is subject to the provisions ofihe t^aws ofthe
Commonwealth ofMassachusefts relating thereto, and upon such teins and coirditions, and to the rules andregulations in regard to lhgcarrying on ofthe occupation so licensed as adopted bythe Board of Health, and
expires December 3l . 2024 unless sooner revoked.
Jwyary l;2024, BOARD OF HEALTH:Hillard Boskty, M.D., Chairman
Maru Crnis. Vice Chnirmnn Clnrles
Holzi,av, Clirk
Eic Weston
Laurunce Venezin, DVM
(date)
James G
Di th
+q 0qI
TOWN OF YARMOUTH
I146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 026il'24r'51
Telephone (508) 398-2231, ext. l24l
Fax (50E) 760'3472
Tvoc of Aoolicetion
oNew fl Renewal ApplicationFee(s): $150/Frcility $55/T
Type(s) ofBody Art D Tattoo Facility
tr Piercing FacilitY
ESTABLISHMEIYT INFORMATION
,dTattooTecbnician tr APPrertice
tr Piercing Technician
q6 OUft{8S
B Name &
(?
ity State
Typoofownenhip: tr Sole Proprietor tr Corporation tr Partnsrship
If establighment is owned by a corpor*ion, partnership, or other combination of individuals, please
attsch the name, title, tax ID#, and home address of all owners'
Ertablirhment Owner's / Techniclarr Nrme:
S rvlo Mr RR\
Middle InitialFirst
lo q
only)irth ax ID
p
fe
Address
N
State zipCty
0t-bq3$,10 at\
Eimal
1
Phone Number
+
I Address
Board of
H€slth
Healttl
Division
Last
JUN 2 O ?.024
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tier
JUAI 2 0 ?0?4
PRIOR LICENSURE
Has the owner or operstor ofthe Pro
!g[!9i4 license or permit?
ld a body art
Ifyes, please list the information below. Attach additional pages if necessary.
fr,"
!No
State/tlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
A]s
Sta unicipality Lic./Cert./Reg. #Status (Active/Exp ired/Suspended)
Has the owner or operetor ofthe proposed establishment ever held a body art I Yes
establishment license or permit?!No
If yes, please list the information below. Atlach additional pages ifnecessary,
State/1\4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
-tare,{r,Iunicipality Lic./Cert./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
EMPLOYEE INFORMATION
Please list and s all Art Technicians lattoo,rcl nlicec
Type ofBody Art
Perlbrmed
Employee Name
)
Creat d I n4D023
No
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 to)
f] Detailed floor and operation plans ofproposed body art establishment (new applicants only)
D A copy ofBlood Exposure Control Plan
D Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
! First Aid and CPR certifications
E Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftercare information and instructions
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 bf Health Body Art Regulations
while practicing in the Town of Yarmouth.
I further underrtand 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.
OS
Full Name of Applica nt c 1t Z.-/
Date
It is your responsibility to renew your permit at the end ofeach calendar year.
3
Ll:
DEPIHEAT
ature
C.eded I /2412023
I hereby certiff, 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.
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