HomeMy WebLinkAboutCollin KelseyTHE COMMONWEALTH OF MASSACH
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBEP. # 24-O67 FEE: $55.00/ rechnician
This is to Certifu that Collin Kelsey
SETTS
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 tenns and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so licensed as adopted by the Board ofHealth, and
expires December 31. 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:
(date)
Hillnrd Boskev, M.D., Chnirmnn
Mnnr Crais. Vice Clutirman Chnrles
Hohrtav, ClirkEic Weston
Laurance Venezia, DVM
Di ealth
James G.
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02654'24451
TelePhone (50E) 39S223l,exL 1241
Fax (50E) 76C3472
Board of
Hcaltt
HcEltt
Divigion
ESTABLISHMENT INFORMATION
s
Narne &
First Last
Z+Lo d lrts
I}pe of ownenhlp: tr Sole Proprietor u Corporation
restablfuhem is owned by a corporation, partnership, or other combindion of individuals, please
attach the name, title, tax ID#, and home addrcss of all owners'
ErtrtlLhment Orrner'r / Tec.hnidrnr Nrme:
State
zx ID
7)
tate
0
zip
D Patnership
J
Middle Initial
lltZ - lq
u/< ,/8
-+
Phone Number
-003
Ct ad lDlA
TVoc of Aoolhdim
o New fl Renewal Aprplicarion Fee(s): $160 / Frctltty $55 / Technicirn $55 / Appronticc
Typ{s)ofBodyArt DTattooFacitity /fanoofe*niciao tr Apprertice
tr Piercing Facility tr Piercing Technician
1
PRIOR LICENSURE
H"* th. o*ou" or operator ofthe proposed establishment ever held a body art
lgb4igi4 license or Permit'.
h additional pages dnecessary.n/I t informati
F*' lNo
Status (Active/ExPired/Suspended)
Status (Activ e/Expired/SusPended)
E Yes
trNo
S unlc
State/lvlunicipal Lic./Cert./Reg. #ity
Has the owner or opentor of the proposed establishment ever held a body art
establishment license or Permit?
Mitt the information below. Attach additional pages if necessary'
SrateA,lunicipality Lic./Cert./Reg. #Status (ActivelExPired/Suspended)
StateMunicipality Lic./Cert.lReg. *Status (ActivelExpired/S uspended)
Town of yarmouth taxes and liens must be paid prior to renewal or issulnce of your permits'
Please check appropriately if paid: Yes---- No ......---'
EMPLOYEE INFORMATIQN
afioo erct a nticeallArt TechniciansPlease list and t
Type of BodY Art
PerformedEmployee Name
)
Crcal/.t 1n4D0
Lic./Cert./Reg. #
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)
! Detailed floor and operation plans ofproposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp' Insurance
D Client application and consent forms
! First Aid and CPR certifications
! Medical Waste Removal Contract
! Bloodbome Pathogen Training
D Aftercare information and instructions
Applicant Statement of Consent
I understand thrt this permit is valid only in the Town of Yarmouth and expires at the end of
the calendar year in which it wss issued.i also understand that any notice to be mailed to me by
the Town of yarmouth Boaid of Heelth will be mailed to the address indicated on this
application.
IhavereceivedrcopyoftheYarmouthBorrdofHealthBodyArtRegulations.Ihaveread
anJ undentand the'obligations and requirements imposed upon a licensed Bo9{ A_Jt
Esteblishmentowner/operatorbythoseregulations.IalsoegreetggolntY'witballofthe
reguletion requirements specifiedin the Yarmouth Board bf He4th Body Art Reguletions
while practicing in the Town of Yermouth'
I further understrnd thrt it is my responsibility to ensure thst individual Body Art Technicians
woiting in tnis establbh,ent have a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, sanitatiotr' sterilization, and
work practices regutetions as specified in the Yrrmouth Bosrd of Health Body Art
Regulations.
I hereby certify, under penalties and pains of perjury, thrt to the best of my knowledge the
information provided on this application is compiete and accurate and in no way misrepresented'
0
Full Name of APPlicant
li
I Z /
Date
It is your responsibility to renew your permit at the end of each calendar year'
3
Signature
Credcd 1,2420