HomeMy WebLinkAboutDustin FowlerTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-068 FEE: $55.00/ rechnician
This is to Certi!that Dustin Fowler
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 5l , ofthe General Laws, and amendments theraol and is subiect to the provisions ofihe La",vs ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and coirditions, and to the rules and
regulations in regard to the carrying on ofthe occupationso licensed as adopted bythe Board ofHealth, and
expires December 3 l, 2024 unless sooner revoked.
Januarv I ,2024, BOARDOFHEALTH:
(date)
Hillard Boskey, M.D., Chnirman
Mnru Crois, Vice Clutirman ChnrlesHoki,av, Cterk
Eic Weston
Laurance Venezin, DVM
James G. G tner
ealth
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-2M51
TelePhone (508) 3 98-2231 , exL l24l
Fax (508) 760-3472
(,
State Y
Board of
Health
TVue of Aoolietion
trNew flRenewal ApplicationFee(s):$160/Facitity $55/Technicien $55/Apprentice
Type(s)ofBodyAr* OTattooFacility fTattooTecbnician tr Apprentice
c Piercing Facility tr Piercing Technician
ESTABLISHMENT INFORMATION
q8 0ulc ,28
g3 3To Un
ling
ty
7a q- a7/'/sz dus h'n
Health
Division
only)
3
/n0L'Car4
c!J
B Name &
Date B
rty
Type of ownenhip: tr Sole Proprietor tr Corporation tr Prtncrship
If establish6ent is owned by a corporation, partnership, or other combination of individuals, plcase
attach the name, title;tax fD#, and home addrcss ofall owners'
Estabtrlhment Owner's / Technichnr Nrme:
TusrN UIEL
First Last Middle Initiat
s{
//
TaxID # (
tate
Email Address
1
Phone Number
/)€
Ctcsft/ lD4n02:
0
L
PRIOR LICENSURE
ff"r tt" owner or operator ofthe proposed establishment ever held a body art D Yes
!q[igi4 license or Permit?o
statea4 uni
I t
pality L Cert./Reg. #
ease I o below. Attach additional pages if necessary.+
Status (Acti Suspended)
State&Iunicipality Lic./Cert./Reg. #Status ( Active/Expired/SusPen ded)
Has the owner or operator of the proposed establishment ever held a body art ! Yes
cstab ment license or permit?nNo
Ifyes, please list the information below. Attach additional pages if necessary.
State,Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State,{\4unicipality 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
enlicePlease list and s c all Art Technicians altoo,terctI
Employee Name
2
Crcat d I /24D023
Type ofBody Art
Performed
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
tr A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
tr Detailed floor and operation plans ofproposed body art establishment (new applicants only)
! A copy ofBlood Exposure Control Plan
n Proof of liability insurance / Workman's Comp' Insurance
! Client application and consent forms
I First Aid and CPR certifications
! 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 wes 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 reed
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 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.
us
ull Name of Applicant
A/-a
Date
It is your responsibilif"v to renew your permit at the end of each calendar year.
3
S ture
Cr.aed I D412023