HomeMy WebLinkAboutEllen StanleyTHE COMMONWEALTH OF MASSACHUSETTS
PERMIT NUMBER: #24-074
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifu that Ellen Stanley
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 terms 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.
January I,2024. BOARDOFHEALTH:Hillnrd Boskeu, M.D., Clnirmnn
l)tJnry Cratg, !ice Chairman Chnrles
t7ol1oav, Llerk
Eic Weston
Laurance Venezia, DVM
(date)
James G. G
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02ffi24r'.51 '
TelePhone (50t) 39&2231' ext 1241
Fax (508) 76&3472
Board of
Hcsl0t
Hedtl
Division
Tvoe of Aoolicetfun
oNew fl Renewal Applicuion Fee(s): $160 / Frcility $55 / Technicirn $55 / Apprcntice
Type(s) ofBody Art D Tattoo Facitity
tr Piercing FacilitY
FfTABLISHMENT INFORMATION
s
Name &
rry
Ertablirhment Owner's / Tcchniclanr Nrme:
Fint Last
/ tattootechician tr APPrentice
D Piercing Technician
q6 OU/< 18
State zip
br b-tl,a'P M
Middle Initial
Typc of omcnhlp: D Sole Pmprietor tr Corporation tr Patnership
If establishsrent is orrned by a corporatiorL parttrership, or other combination of individuals, please
attach the name, title, tax IB, and home address of all owners'
zlx ID
rJr
f'a zz8
State
A,4h
1
Z
C'lefd lD4Dt
*/#q;
PRIOR LICENSURE
Has the owtrer or operrtor of the proposed estrblishment ever held a body art
!9g@ig!4 license or Permit?necessaryAyet'ease list the information below. Att
4 L
Status (ActivelExpired/SusPended)Sta ipality Lic./Cert./Reg.#umc
Has the owner or operator ofthe proposed establishment ever held a body art
estsblishnent license or Permit?
ffi'ttheinformarionbelow.Atlachadditionalpagesifnecessary,
State/I4unicipalitY Lic./Cert./Reg.#
State/lrlunicipalitY Lic.i Cert./Reg. #
State,Municipality Lic./Cert./Reg.#
EMPLOYEE INFORIVIATION
Status (Active/Expired/S uspended)
E Yes
trNo
Status (Active/ExPired/Sus pended)
Sratus (Active/Expired/S uspended)
nticeallArt Technicians 'tattoo,rercl
TownofYarmouthtaxesandliensmustbepaidpriortorenewalorissuanceofyourpermits.pr"*" "rr..t "ppropriately
if paid: Yes...."-- No ..--........---'
Please list and J
Employee Name
Z
CP!z,'.d 1 124120
-FJ"'/ nNo
Type of BodY Art
Performed
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
D A copy ofowner's valid identification card with- picture
(statd-issued license, passport, or military-issued Io)
! Detailed fl,oor and operation plans of proposed body art establishment (new applicants only)
D 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
tr Aftercare information and instructions
Applicant Statement of Consent
I undentand thet this permit is valid only in the Town of Yarmouth and expires at the eud of
in.G.oa". v.rr in wiich it wss issued.i elso understand that rny 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 Yermouth Borrd of Health Body Art Regulations- I have read
and understand the o-bligations and requirements imposed upon a licensed noly 'l'-Jt
Bstetnsnmentowner/operatorbytho.seregulations.Ialsoeg."etocomplywilhallofthe
regulation requirements specifiedin the Yaimouth Borrd bf Herlth Body Art Regulations
while practicing in the Town of Yarmouth'
I further understand that it is my responsibility to ensurc th&t individual Body Art Technicians
*ort<ing in this establfuhment have a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable heatth, 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 o, tUis "pptication is compiete and accurrte and in no way misrepresented'
C,L!U){arkzL L
Full Name of Ap t
u
Date
It is your responsibility to renew your permit at the end of each calendar year'
3
creared lD4l20:
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