HomeMy WebLinkAboutJasper CapwellTHE COMMONWEAL o A ETTS
PERMIT NUMBER: # 21-014
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: S55.00/ Technicran
This is to Certi& tlnt Jasper Capwell
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 ro the Board of Health, by Chapter 140,
Sections 5l . ofthe General Laws, and amendments theretol and is subject to the provisions ofihe LaiNs ofthe
Commonwealth of Massachusetts 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 of Health. and
expires December 31. 2024 unless sooner revoked.
lanuaw 1.2024. BOARD OF HEALTH:Hillnrd Boskeu, M.D., Chnirmnn
Moru Crnis. Vice Clnirnan Chnrles
Holzi,av, dirkEic Weston
Lnurance Venezin, DVM
(date)
James G.
ealth
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 0266+2445I
Tele?hone (50E) 39V2231,e* l24l
Fax (50E) 76G3472
Board of
Hcal&
Healtr
Division
Tvoe of Aoolicetion
ENew fl Renewal Application Fee(s): $160 / Frcility $55 / Technicirn S55 / Apprtntice
I}pe of ownenhip: tr Sole Proprietor tr Corporation D Patnenhip
If' establishent is ou,ned by a corpoution, partnership, or other combination of individuls' please
atach the namc, title, tax ID#, and home address of all owners'
ErtrtlLhmcot Owner'r / Techrldanr Nrmc:
Type(s) of Body Art D Tatt,oo Facility
tr Piercing FacilitY
ESTABLISHMENT INFORMATION
Snrrt r\Ait'K_BffiNa*eE
First Last
L7r
0
-3qbLl -+
,d fattoofechician tr APPre'lrtice
tr Piercing Technician
0uft18
State
ax ID
State
b
Iflitial
only)
4 /0 - /32
5
ll.yt
1
Phone Number
3
Crt.Ed 12421
PRIOR LICENSURE
Has the owner or operator ofthe proposed establishment ever held a body art
technician license or Permit?
e list the informatio n below. Attach additional pages if necessary.5
es
DNo
Status (Active/Expired/Suspended)
-tatus(Active/Expired/S uspended)
D Yes
trNo
S unicipality Lic./Cert./Reg. #
unicl ty Lic./Cert./Reg. #
tq 3n
Has the owner or operator of the proposed establishment ever held a body art
establishment license or Permit?
Mu titt the infoiation below. Auach additional pages i-f necessary'
StateA4unicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State,MunicipalitY Lic./Cert./Reg. #Status (Active/ExPi red/Suspended)
Town of Yarmouth tixes and liens must be paid prior to renewal or issuance ofyour permits'
Please check appropriately if paid: Yes-- No
EMPLOYEE INFORJUATION nlicePlease list and s Art Technicians attoo,rct
Type ofBodY Art
PerformedEmployee Name
2
Cr.dcd 1D4D0
all
Requirements for Body Art Establishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification card with- picture
(stat6-issued licanse, passport, or military-issued Io)
tr Detailed floor and operation plaas of proposed body art establisbment. (new epplicanh only)
! A copy ofBlood Exposure Control Plan
tr Proof of liability insurance / Workman's Comp' Insurance
I Client application and consent forms
D First Aid and CPR certifications
n Medical Waste Removal Contract
! Bloodbome Pathogen Trainilg
! Aftercare information and instructions
Applicant Statement of Consent
I understend thrt this permit is valid onty in the Town of Yarmouth and expires at the end of
tn" J"ra". y"ar in wiich it was issued. i also understand that rtry 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 Hedth Body Art Regulations- I have read
snd undentsnd the obfgations and requirements imposcd upon a licensed Bod1, A1t
Estrblishment owner/operator by those regulrtions. I also egree to comply with all of the
reguletion requirementsipecified in the Yarmouth Board bf Health Body Art Regulations
while precticing in the Town of Yennouth'
I further under,stand that it is my responsibility to ensure thst individual Body Art Technicians
working h this establhhment have a current vatid Yrrmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, senitation, sterilization, and
work precfices reguletions as specilied in the Yermouth Board of Health Body Art
Regulations.
I hereby certiry, under penalties and pains of perjury, that to the best of my knowledge the
informetion provided on tnis application is complete end rccurate and in no way misrepresented'
Full N e f Applicant
It is your responsibitit"v to renew your permit at the end ofeach calendar year'
4
ture
Creared I 24,20
3