HomeMy WebLinkAboutScott AlthenOMMONWEALTH OF MASSACHUS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu that Scott AIthen
at Soilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued ir conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, ani amendments theretol and is subject to the provisions ofihe Laws ofthd
Commonwealth of Massachusetts relating thereto, and upon such terins and coiditions, and to the rules and
regulations in regard to the carryilg on ofthe occupation so licensed as adopted bythe Board of Health, and
expires December 3l , 2024 unless sooner revoked.
Januarv I ,2024. BOARDOFHEALTH:Hillnrd Boskey, M.D., Chnirman
Mnru Crais, Vice Chnirmon CharlesHoli,nv, Cltrk
Eic Weston
Laurnnce Venezia, DVM
(date)
James ardiner
of Health
PERMIT NUMBER:# 24-049
TOWN O F YARMOUTH
I146 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS 02664'24451
Telephone (50E) 398-2231, ext. l24l
Fax (508) 760-3472
Tvpe of Aoolication
E New fl RenewA Application Fee(s): $150 / Factlity $55 / Technicirn
Bosrd of
Health
Hcalth
Division
_ v ._=.c
iUiy 2 o Z0Zl
HL4J.TH
Type(s) of Body ArI O Tattoo Facility
D Piercing FacilitY
ESTABLISHMENT INFORMATION
f Tattootectnician tr APPrentice
tr Piercing Technician
q8 0u/< ,/8
zip
tr Partnership
S
Buslness Name &
(?
rty State
Type ofownerrhip: tr Sole Proprietor tr Corporation
If estsblishment is owned by a corporatiorl partnerstrip, or other combination of individuals, please
attach the name, title, tax ID#, and home address ofall owners'
Ertabfuhment Owner's / Technicisnr Nrme:
Jcorr Middle InitialFirst
Z
b6
ofB
Last
Gender TaxID#(ishment only)
44
L rng
(,*3tsLL/-7
City State
Email
p
4-d-i
1
Number
0 OZ
ctcsai lD4D02:
PRIOR I,ICENSURE Ear-
Has the owner or operator of the proposed establishment ever held a body
technician license or permit?
If yes, please list the information below. Attach additional pages dnecessary.
H TH O€D>
CS
DNo
State/Ir4unicipality Lic./Cert.iReg. #Status (Active/Expired/Suspended)
7
Sta cipality Lic./Cert./Reg. #
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information belov,. Attach additional pages if necessary.
Status (Active/Expired/Suspended)
E Yes
trNo
StateMunicipdity Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State^4unicipality Lic./Cert./Reg. #Status (Activei 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 No
EMPLOYEE INI'ORMATION
Please list and s all Arl Technicians attoo,tercln a entice
Type ofBody Art
Performed
Employee Name
)
Crcated I D412023
, lJ,tr j !i :izt
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
D A copy ofowner's valid identification card with picture
(statd-issued license, passport, or military-issued to)
! Detailed ftroor and ope.ralion plans of proposed body art establishment (new applicants only)
! A copy ofBlood Exposure Conuol Plan
D Proof of liability insurance / Workman's Comp' Insurance
tr Client application and consent forms
E First Aid and CPR certifications
! Medical Waste Removal Contract
! Bloodbome Pathogen Training
! Aftercare information and instructions
f----=-=-_=-
,tUlt i U ZO?4
HEA IHO,co >t
Applicant Statement of Consent
IunderstandthatthispermitisvalidonlyintheTownofYarmouthandexpiresattheendof
the calendar year in which it was issued.i also understand that any notice to b-e mailf to me by
theTownofYarmouthBoardofHealthwillbemailedtotheaddressindicatedonthis
application.
IhavereceivedacopyoftheYarmouthBoardofHealthBodyArtRegulations.Ihaveread
"oa unOemtanO the obligations and requirements imposed upon a licensed nofl a1t
Estrblishment Owner/operalitj firose reguletions' I also agree t9 9o1nly wifh all of the
regulation requirements specified"in the Yaimouth Board bf Health Body Art Regulations
while practicing in the Town of Yermouth'
I further understend that it is my responsibility to ensure that individual Body Art Technicians
'o.r.iogiothisestablishmeoth",.".u.".ntvalidYarmouthBoardofHealthBodyArtTechnician License and .o.plv *i,t all applicable health, safety, sanitation, sterilization' and
work practices regulations as specilied in the Yarmouth Board of Health Body Art
Regulations.
Iherebycertify,underpenaltiesandpainsofperjury,thattothebestofmyknowledgethe
information provided ", tfri.-"ppli""iion i, compiet" and accurate and in no way misrepresented'
Full Name of A plicant
L /
It is your responsibility to renew your permit at the end of each calendar year.
3
ature
Crcated I 12412023