HomeMy WebLinkAboutJustin RodriguezTHE CO ALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certifo fhAl Justin odrisuez
at SDilt 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 therdlo] and is subiect to the provisions ofihe taws ofthe
Commonwealth ofMassachusens relating thereto, and upon such terins and coirditions, and to the rules and
regulations in regard to thecarrying on ofthe occupation so licensed as adopted by the Board ofHealth. and
expires December 31, 2024 unless sooner revoked.
Jantary 1.2024. BOARD OF HEALTH: Hillard Boskev, M.D., Cltnirman(date) Mary Craig,Vice Chnirnnn CharlesHoli,nv, derkEic Weston
Lnurance Venezia, DVM
James G
th
PERMIT NUMBER: # 24-069
TO WN OF YARMOUTH
1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02654-2445I
Telephone (50E) 39E 2231' ext. 1241
Fax (50E) 760'3472
Board of
Health
Health
Division
Tvoe of Aoolication
D New fl Renewal Application Fee(s): $160 / Facility $55 / Technician $55 / Apprentice
f Tattoo Techician D APPrentice
tr Piercing Technician
er)q8 Kou/< '28
B Name &
Type(s) ofBody ArI D Tattoo Facility
tr Piercing FacilitY
ESTABLTSHMENT INF1ORMATION
7
State zip
Type of ownenhip: tr Sole Proprietor tr Corpotation D Partnership
If establishment is owned by a corporation, partuership, or other combination of individuals, plcase
attach ttre name, title;tax ID#, and home address of all owners'
Establichment Owner's / Technlcianr Nrme:
5T//1/UE
First Last Middle Initial
Date TaxlD#(
/'5Z
c D VN a3daa- 6//1
State
0tr|
U
/L
EmailPhone Number
- ls/- 022/
Address
0u/s /tct e
Crc'tret lD4D02i
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1
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
!g[i9!4 license or permit?
below. Attach nal pages if necessary.
E Yes
trNo
Status (Acti irediSuspended)
s,ease list the idormatior.tF
State/Municipality Lic./Cert./Reg. #
State/Tvlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended.l
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.
E Yes
trNo
State/Iilunicipality Lic./Cert./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 renewtl or issuance of your permits.
Please check appropriately ifpaid: Yes- No
EMPI,()YEE INFORMATION
Please list and s all Art Technicians altoo,terct ntice
Type ofBody Art
Performed
Employee Name
)
crcated I /24/2023
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! 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)
n A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp' Insurance
tr Client application and consent forms
E First Aid and CPR certifications
! Medical Waste Removal Contract
! Bloodbome Pathogen Training
n 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 iarmouth Board of Health will be mailed to the address indicated on this
application.
I have received a copy ofthe Yermouth 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 specilied 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 certis, 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'
Osfnt Pa><tdDrz
Full Name of Applicant
te
It is your responsibility to renew your permit at the end of each calendar year'
J
Created I D412023