HomeMy WebLinkAboutSeth CampbellTHE COMMONWEALTH OF MASSACHUSE
TOWNOFYARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-063 FEE: $55.00/ rechnician
This is to Certiry ftat ell
at Spilt Milk
Hillnrd Boskev, M.D., Clnirnnn
Maru Crais. Vice Chairmnn CharlesHoli'nv, C-firkEic Weston
Laurance Venezia, DVM
Jantary 1,2024, BOARD OF HEALTH:
(date)
James G
Direc
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 subiect to the provisions ofthe l-aws ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so hcensed as adopted by the Board of Health, and
expires December 3l . 2024 unless sooner revoked.
TOW N OF YARMOUTH
I 146 ROUTE 2E, SOUTH YARMOUTH, MASSACHUSETTS 0266+2'145I
TelePhone (508) 39&12231, ext' 1241
Fax (50E) 760'3472
Board of
Health
Health
Division
Tvre of Aoolication
O New fl Renewal Appticuion Fee(s): $160 / Facility $55 / Technician $55 / Apprentice
Type(s) ofBody Art trTattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INtr'ORMATION
B Name &
itv
Est bllshment OwDer's / Technicisnr Name:
y'TanooTechaician tr APPrentice
tr Piercing Tecbnician
q8 0uft18
(?
State p
Typc of ownenhip: tr Sole Proprietor tr Corporation tr Partnership
If establishment is owned by a corporation, partnership, or other combination of individuals' please
attach the name, title, tax IH, and home address of all owners'
SETH
First
Date
ELL
?s
Middle Initial
v)Tax #
€0 5v
Legal
L)oBcts rE/_o/6 a$
zipty/a/l Carrt
State
EmailPhone
ad 7s
Address
4/)dqe
Crc,,trn 1D412073
s
c
2
o
o{-
1
PRIOR LTCENSURE
Has the owner or operator ofthe proposed establishment ever held a body art I Yes
technician license or permit? nNo
Ifves. olease list the information below. Auach additional oases if necessan).zaro@ lnn b4P e3-5- " u4,,tst-atenaunicipaiti--inlcett:Eie*#
State/Ir4unicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art D Yes
establishment license or permit? tr No
Ifyes, please list the information below. Attach additional pages ifnecessary.
StateiMunicipality Lic./Cert.iReg. #Status (Active/Expired/Suspended)
State/Ir,lturicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuanee of your permits.
Please check appropriately ifpaid: Yes No
EMPLOYEE INFORMATION
Please list and all Bo Art Technicians tattoo,terct entice
Type ofBody Art
Perlormed
2
C.eded lD4n023
Employee Name
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
D A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
tr Detailed floor and operation plans of proposed body art establishment (new applicants only)
E A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp. Insurance
n Client application and consent forms
n First Aid and CPR certifications
tr Medical Waste Removal Contract
! Bloodbome Pathogen Training
tr 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 hereby certifo, 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.
SE
Full Name of A nt
?OQ
Date
It is your responsibitity to renew your permit at the end ofeach calendar year.
J
Signature
Crcat d I 124D023
I have received I 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.