HomeMy WebLinkAboutRichard WillguesJames G.
THE COMM MASSA ETT
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-046 FEE: $55.00/ Technician
This is to Certi$/that Richard Willzues
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
Commonweallh of Massachusens 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 of Health, and
expires December 3l,2024 unless sooner revoked.
Januarv I ,2024, BOARDOFHEALTH:Hillard Boskey, M.D., Chnirman
Maru Crais. Vice Clmirmnn CharlesHolfinv, Oerk
Eic Weston
Laurance Venezia, DVM
(date)
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TOWN OF YARMOUTH
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Board of
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Health
DivisionI 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSE
Telephone (50E) 39E-2231, ext l24l
Fax (508) 760'3472
Application Fee(s): $160 / Facility $55 / Technician $55 /
Tvoe of Apolication
oNew fl Renewal
Type(s) ofBodyArt D Tattoo Facility
I Piercing FacilitY
ESTABLISHMENT INFC'RMATTON
,,d Tattoo Technician tr APPrentice
tr Piercing Technician
s
B Name &
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tty State Zip
Typc of ownenhip: tr Sole Proprietor tr Corpomtion D Partnemhip
If establishment is ormed by a corporation, parhership, or othet combination of individuals, plcase
attach the name, title, tax ID#, and home address of all owners.
Ertablirhment Owner's / Technicians Name:
First Last Middle Initial
B Gender Tax ID (establ ishment only)
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PRIOR LICENSURE
Has the owner or operator of the proposed estab y art zfres
nNolq$jgjg license or Permit?ffi*t, I i s t t he i ifor mar i on below. Attach additional pages ifnecessary
State,{r4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
cl I Lic./Cert./Reg. #Status (Active/Expired/Suspended)
! Yes
trNo
Has the owner or operator ofthe proposed establishment ever held a body art
esta hment license or permit?
Ifyes, please list the information below. Attach additional pages if necessary.
State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/lt lunicipality Lic./Cert./Reg. #Status (Active/Exp ired/Suspended)
Town of Yarmouth trxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately if paid: Yes-
EMPLOYEE INFORMATION
nticeall B Art TechniciansPlease list and s i atloo,erctn a
Type ofBody Art
PerformedEmployee Name
2
No
Cr..dID412023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
D A copy ofowner's valid identification card with picture
(stat6-issued license, passport, or military-issued to)
tr Detailed floor and operation plans ofproposed body art establishment (new applicants only)
D A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
n First Aid and CPR certifications
n Medical Waste Removal Contract
! Bloodbome Pathogen Training
tr Aftercare information and instructions
Applicant Statement of Consent
Full Name of Appl
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 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 understsnd the oiligations and requirements imposed upon a licensed noly.{t
Establishment Owner/Operator by thoie regulations. I also agree to comply with 8ll of the
regulstion 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.
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'
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It is your responsibitity to renew your permit at the end of each calendar year.
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