HomeMy WebLinkAboutErik SmileyTHE MMONWEALTH OF MASSA E
PERMIT NUMBER: # 24-065
TOWN OF YARI}IOUTH
BOARD OF HEALTH
FEE: S55.00/ Techrician
This is to Certifu Erik Smil
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 of Massachusetts relating thereto. and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health, and
expires December 31, 2024 unless sooner revoked.
lanuary 1,2024, BOARD OF HEALTH:Hillard Boskey, M.D., Chairnnn
Maru Crnis.Vice Clninnnn Charles
Hold,nv, Cfirk
Enc Weston
Laurance Venezia, DVM
(date)
J G
rh
TOW N OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-2445I
TelePhone (50E) 39U2231, qt 1241
Fax (508) 760-3472
Board of
Healtlr
Health
Division
ESTABLISHMENT INFORMATION
S
B Name &
ltl,
Last
Typc of ownenhip: tr Sole Proprietor tr Corporation
If establishment is owned by a corporation, parmership, oI other combinstion of individuals, plesse
attach the name, title, tax ID#, and home address of all owners'
Estrblfuhment Owner'r / Technlcianr Nrme:
9/l/ te
fuflrs0lU lk-cn 76
City
q8 OUft{8
(?
zip
tr PartnershiP
Middle Initial
'&tn*
State
Tax ID?r7
Date
3
Legal
L
Phone Number Address
u'e 4/
er"di/ \D4D0X1
IVoe of Anolicedon
oNew flRenewal ApplicationFee(s):$1()/Facility $Ss/Tcchnicirn $Ss/Apprentlce
Type(s)ofBodyArt trTaftooFacility /fattootectnlcian trApprentice
tr Piercing Facility tr Piercing Teclrnician
First
0
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
tclan license or permit?
the tion ore. Attach ti
n Yes
trNo
e e
State/Iv1 unl
ne
cipality Lic.lC ./Reg. #Status (Active/Expi
State/Municipality Lic.iCert./Reg. #Status (Active/Expired/Suspended)
E Yes
!No
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information below. Attach additional pages ifnecessary.
State,Municipality Lic./Cen./Reg. #Status (Active/Expired/Suspended)
State/Municipality 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 if paid: Yes_No
EMPLOYEE INFORMATION
Please list and s all B Arl Technicians lattoo lerctn nticect
Employee Name Type ofBody Art
Performed
2
Cftated I /2412023
*
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
n A copy ofowner's valid identihcation card with picture
(state-issued license, passport, or military-issued tn)
! 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
! Client application and consent forms
n First Aid and CPR certifications
! Medical Waste Removal Confiact
! Bloodbome Pathogen Training
! 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 wiich it was issued.i also understand that any notice to be mailed to me by
the Town of iarmouth Board of Health will be mailed to the address indicated 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
Estabtishment owner/oierator by those regulations. I also agree to comply with all of the
regulation requirements specified in the Yarmouth Board bf Health Body Art Regulations
while practicing in the Town of Yermouth.
I further understand that it is my responsibility to ensure that individual Body Art Technicians
working in this establishment have a iurrent 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.
trp/k 5m/LEr
Full Name of A plicant
2aa
3
ature
Crc,J..ed I D412023
It is your responsibility to renew your permit 8t the end ofeach calendar year.