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Home My WebLink AboutMarshall BrownPERMIT NUMBER: # 24-066 HE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH FEE: S55.00/ Technician This is to Certifu that Marshall Brown 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 ganted to the Board of Health, by Chapter 140, Sections 51, ofthe General Laws, ani amendments therito, and is subj ect to the provisions of the.Laws ofthe Commonwealth ofMassachusetts relatine thereto, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on olthe occupation so licensed as adopted by the Board ofHealth, and expires December 31. 2024 unless sooner revoked. Hillard Boskev, M.D., Chairman Mnru Crais. Vice Chairnmn Charles Holi,au, ClirkEic Weston Laurance Venezia, DVM Januarv 1.2024. (date) BOARD OF HEALTH: James G. G th TOWN OF YARMOUTH I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Telephone (508) 398-2231 , ext' l24l Fax (50E) 760'3472 Board of Health Health Division Tvoe of Apolication ! New fl Renewal Application Fee(s): $f60 / Facility $55 / Tcchnicien $55 / Apprtntice Type(s) of Body ArI n TattLoo Faciliry tr Piercing FacilitY ESTABLISHMENT INFORMATION s Buslness Name & lty f fattootecbnician tr APPrentice tr Piercing Technician q8 OU/< "28 (? State p Typc of ownerrhip: tr Sole Proprietor tr Corporation tr Partnership If establishment is owned by a corporatior\ Partnership, or other combination of individuals, please attach the name, title, tax ID#, and home address of all owners' Establirhment Owner's / Technicianr Name: /iln 2slnt/DRoctt q First Date B C ty Last 3u Middle Initial 3 7 TaxlD#(ishment only) L, Address IL 2 State 2a lnars, braun 1 Phone Number sal @ )/ .eat1 Crcat n lD4n02: PRIOR LICENSURE Has the owner or operator ofthe proposed establishment ever held a body art ! Yes !q@!g@ license or permit? nNo s,list the inlbrmotion below. Attach additional pages if necessary.e 33 unicipal Lic./Cert./Reg. #Status (Active/Expired/Suspended)S State/lr4unicipality 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 i-fnecessary. Status (Active,/Expired/Suspended) E Yes DNo StateA,Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) State/Municipality Lic.iCert./Reg. #Status (Active/Expiredi Suspended) Town of Yarmouth trxes 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 cl all B Art Technicians attoo,ercl a rce Type ofBody Art Performed Employee Name 2 Crea,3d I D412023 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 of proposed body art establishment (new applicants only) ! A copy ofBlood Exposure Control Plan ! Proof of liability insurance / Workman's Comp. Insurance tr Client application and consent forms n First Aid and CPR certifications I Medical Waste Removal Contract ! Bloodbome Pathogen Training ! 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 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 Establishment Owner/Operator 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 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 appticable 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. /lnzs*ntL G, bRoclu Full Name of Applicant (, It is your responsibilit"v to renew your permit at the end ofeach calendar year. Da 3 S ture cteated I t24/20?)