HomeMy WebLinkAboutDaniel Lapcheske 2James G.
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-064 FEE: S55.00/ rechnician
This is to Certili that Daniel Lapcheske
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 authonty granted to the Board of Health, by Chapter 140,
Sections 5l , 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 Iicensed as adopted bythe Board of Health, and
expires December 3 t, 2024 unless sooner revoked.
Hillard Bosky, M.D,, Chairman
Maru Crnis. Vice Chnirmnn Cfuirles
Hokrtau, Cli*Eic Weston
Laurance Venezia, DVM
lanuarv 1,2024, BOARD OF HEALTH:
(date)
rh
net
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSEfiS 02654'2445I
Telephone (508) 39E-2231, ext 1241
Fax (50E) 760'3472
Board of
Health
Health
Division
Tvoe of Aoolicstion
DNew fl Renewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice
Type(s) ofBody Art: trTattoo Facility
D Piercing FacilitY
ESTABLISHMENT INFORMATION
,d Tattoo Technician tr APPrentice
tr Piercing Teohnician
OUft ,28S
B Name &
(?
lty State
Typc of owncrrhip: tr Sole hopri*or tr Corporation tr Partn€rship
If establishment is owned by a corporation" partnership, or other combination of individuals' please
attach tho name, title;tax ID#, and home address of all owners.
EstrblLhment Owner's / Tech cianr Name:
UPC,/e*E
First Last Middlehitial
oa /7 7q/ n
Date Tax ID (establ enly)
/7/0
fr!,4/1)
City
Tfr SaoaB
State zip
Email Address
L
Phone Number
- 70/6
Cr!.,et tr24D023
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
technicien license or permit?
Ifyes, please list the information below. Artach additional pages if necessary."faut0 "7vr-- A- /i0?
E Yes
trNo(4'
StateA4unicipality I-ic"tC-rt,rneg.7
State/Municipality Lic./Cert./Reg. #
E Yes
trNo
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
If yes, please list the information below. Attach additional pages if necessary.
State^{micipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Irrtunicipality 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 all Art Technicians tattoo,erct enlice
Employee Name Type ofBody Art
Performed
2
Cnated I /242023
Status (ActiveiExpired/Suspended)
I further understand that it is my responsibility to ensure that individual Body Art Technicians
working in this establishmcnt 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.
--;\
cn,,t )rL lfrPclrstE
Pull Name of Applicant
z aoa
a
It is your responsibility to renew your permit at the end ofeach calendar year.
3
lgnature
Crcated 1D4t2023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy ofouter's valid identification card with picture
(state-issued license, passport, or military-issued ro)
tr Detailed floor and operation plans of proposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
n First Aid and CPR certifications
E Medical Waste Removal Confiact
n Bloodbome Pathogen Training
! Aftercare information and instructions
Appticant 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 of the Yarmouth Board of Health Body Art Regulations. I have read
and understsnd the obtigations 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 specilied in the Yarmouth Board of Health Body Art Regulations
while practicing in the Town of Yarmouth.