HomeMy WebLinkAboutKevin HennesyYa>THE COMMONWEALTH OF MASSACHUSETTS
TOWI\ OF YARMOUTH
BOARD OF HEALTII
PERMIT NUMBER: # 24-062 FEE: $55.00/ rechnician
This is to Certifu fhir+Kevin Hennesv
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 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 by the Board of Health, and
expires December 31. 2024 unless sooner revoked.
Jawarv 1,2024, BOARD OF HEALTH:
(date)
Hillard Bosl<ev, M.D., Chnirman
Mnru Crais. V ice Chnirmnn Chnrles
Hohi,nv, Airk
Eic Weston
Laurance Venezia, DVM
James G
Director o th
-*-/-*-""C. rl^rt-
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
Telephone (508) 39t-2231, ext. 1241
Fax (50E) 760-3472
/v 78
Tax ID #
Board of
Health
Health
Division
Tvoc of Aonlicrtion
trNew flRenewal AppticationFee(s):$160/Facility $55/Technician $55/Apprentlce
Type(s) ofBody Art f Taftoo Facility / fattoo technician tr Apprentice
tr Piercing Facility I Piercing Tecbnician
ESTABLISHMENT INTOR,MATION
Srrtttt,t;t(q8 0uft18
B"siEss Name'&
7b
ty zip
Type of ownership: D Sole Proprietor tr Corporation tr Partn€rship
If establishment is owned by a corporation, partuerstrip, or other combination of individuals, please
attach thc name, title, tax ID#, and home address of all owners.
Establlthment Owner's / Technicians Nsme:
Hraars
First Last Middle Initial
Date
/5-T0/U
gal
t/E<
State
Email
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zip
ss
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ber
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P
ose lisl tion bel Attach additionaleI
! Yes
trNo
necessary.
Status (Active/Explred/Suspended)State,Municipali Lic./Cert./Reg. #
State/Municipality Lic./Cert./Reg. #
Has the owner or operator of the proposed establishment ever held a body art
establishment license or permit?
If yes, please list the information below. Attach additional pages if necessary.
Status (Active/Expired/Suspended)
O Yes
trNo
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/lvlunicipality 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 ifpaid: Yes_No
EMPLOYEE INFORMATION
Please list and s,ci Art Technicians oo,tercl entice
Type ofBody Art
Performed
Employee Name
2
cr.ared lD4D023
BreUENUBE
Has the owner or operator ofthe proposed establishment ever held a body art
technician license or permit?
all
n
n
!
n
E
!
!
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
A copy of owner's valid identification card with picture
(state-issued license, passport, or military-issued Io)
Detailed floor and operation plans of proposed body art establishment (new applicants only)
A copy of Blood 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
Bloodborne Pathogen Training
Aftercare information and instructions
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 indicrted 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 of Health Body Art Regulations
while practicing in the Town of Yarmouth,
I further understand 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 certi$, 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.
Full Name o Applicant
/N
Date
It is your responsibility to renew your permit at the end of each calendar year.
0
J
Signature
Created I D412011
Applicant Statement of Consent