HomeMy WebLinkAboutDavid NielsenTHE COMMONWEALTH OF MASSACHUSE
TOWN OFYARMOUTH
BOARD OF HEALTH
PERMITNUMBER:#24-071 FEE: $55.00/rechnician
This is to Certifu that David Nielsen
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 coirditions, 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 1,2024, BOARD OF HEALTH:
(date)
Hillard Boskey, M.D., Chairman
Maru Crais. Vice Chnirmnn CharlesHoli,nv, Clirk
E,ic Weston
Lnurnnce Venezin, DVM
James G. G tner
rh
TO WN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664'2445I
Telephone (50E) 39E 2231, exL 1241
Fax (50E) 760'3472
Board of
Health
Hcalttr
Division
Tvoc of Aoolicrtiol
oNew fl Rencwal
Type(s) ofBody Art:
ESTABLISHMENT INFORMATION A
b u/< 18
Application Fe(s): $160 / Frclttty $55 / Technicirn $55 / Apprtntice
n Tafioo Facility f tattoo fechician D Apprentice
tr Pietcing Facility ! Piercing Technician
s 0
B Name &
Stat€rp
Typo of omcnhip: tr Sole Proprietor tr Corporation D Prmership
If estabtisboent is oumed by a corporation, PuOership, or otber combination of individuals, plcase
attach the oane, title, ta:t ID#, and home address of all owners'
Ertrbfirhmeut Owner'r / Tcchnlclau Neme:
0 Nid ,\/i d lvl
Last Middle Initial
f0tl
First
L +q
3-
ax ID
tate
0("-zb)
C)
1
Number
Ctcald lD4ll
PRIOR LICENSURE
Has the owncr or operator of the proposed establishment ever held a body art ,9ffes
technician license or Permit?
Ifyes,list the ine tion below. Attach additional pages if necessarY.
!No
Status (Active/Expired/Suspended)
Status (Active/ExPired/Suspended)
LI YES
nNo
State/lr4uni cipality Lic./Cert.
Starc/Municipality Lic./Cert./Reg. #
Has the owner or operator of the proposed establishment ever held a body art
$trbli$hment license or Permit?
i@ utt the information belo*. Auach additional pages if necessary'
StateMunicipality Lic./Cert./Reg. #Status (Active/ExPired/Suspended)
StateMunicipality Lic./Cert./Reg. #Status (Active/ExPirediSuspended)
Town of yarmouth trxes and liens must be paid prior to rtnewal or issuance of your permits'
Please check appropriately ifpaid: Yes--No
EMPLOYEE INFORMATION nticePlease list and all Art Technicians lattoo,rerc
Type ofBodY Art
PerformedEmployee Name
Crearcd t 2420
2
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
E A copy of owner's valid identification card with. picture
(stat6-issued license, passport, or military-issued Io)
tr Detailed It,oor and operation plans of proposed body art establishment (new applicants only)
I A copy ofBlood Exposure Conuol Plan
! Proof of liability insurance / Workman's Comp' Insurance
D Client application and consent forms
tr First Aid and CPR certihcations
E Medical Waste Removal Contract
I Bloodbome Pathogen Training
! Aftercare information and instructions
Applicant Statement of Consent
I understand thet this permit is valid only in the Town of Yarmouth and expires at the end of
tn"-."f.oa". y.ar in wf,ich it wss issued.i also understand that any notice to be mailed to me by
the Town of iarmouth Board of Herlth will be mailed to the address indicated on this
application.
I have received e copy ofthe Yarmouth Borrd of Health Body Art Reguletions- I have read
rnd undentrtrd the o-bligations and requirements imposed upon a licensed foly a1t
Esteblishment owner/operator by those regulations. I also agree to comply with all of the
regulation requirementsipecified in the Yermouth Board bf Health Body Art Regulations
while practicing in the Town of Yrrmouth'
I further undentrnd thrt it is my responsibility to ensure thrt hdividual Body Art Technicians
working in this establishment heve a iurrent valid Yermouth Board of Health Body Art
Technician License and comply with all applicable health, safety, sanitation, sterilization, and
work practices regulations as specified in the Yrrmouth 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 compiete and accurate and in no way misrepresented'
Name of A nt
It is your responsibility to renew your permit at the end of each calendar year'
ateature
Creded L24r0
3