HomeMy WebLinkAboutNicholas SanocaTHE COMMONWEALTH OF MASSACHUSETTS
TOWN OFYARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-073 FEE: $55.00/ rechnician
This is to Certifu that Nicholas Sanoca
at Spilt Milk
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING)
This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe Laws ofthe
Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so licensed as adopted by the Board of Health, and
expires December 31, 2024 unless sooner revoked.
Hillard Bosl<eq, M.D., Clnirmnn
Mara C rnis. V ice Clnirmnn Charles
Hokfiny, Ctirk
Eic Weston
Laurance Venezia, DVM
lanuary 1,2024, BOARD OF HEALTH:
(date)
J**V*--
/ J^ ." G. Gar\iner/ Directo -fuealth
TOWN OF YARMOUTH
I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02654'24451
TehPhone (50t) 39&2231' ext 1241
Fax (50E) 76G3472
Boartl of
Hc.lth
Hcalth
Division
edAdger
oNcw fl Rcoewal Applic*ioa fo{$: $160 / Fecllfty $55 / Tcchnicirn $ltll / Apprutice
Typ{s) of Body Art tl Tattoo Fscility
tr Piercing FacilitY
NSTAELISHMENT INNOR}IATION
0 u/< 18s
Busltress Name &
Srde zip
Typc of owncnhlp: tr Sole hopriaor tr Corpot*ion
tf €6tablfuh€nt is oumed by a corporation' pet1e6hip, or other combfuation of individuals' plcare
attach tho namc, title;tax lf,#, and homc ad&ess of all ou'ners'
Ertrbffinat Orvacr's / TerDDld.lr il.Dc:
f fattoofecUicim D APPrentice
tr Piercing Technician
\aN0 /-
First
Dat€
L,ast Middle Initial
ax ID
NJ 07,02t52
State
q
q6
1
Phone
-(ebq- +,ZQ
C)rd t24r!
PRIOR, LTCENSIJRE
Has the owtrer or opentor of the proposed esteblishment ever held a body art Fes
lggbgglg license or permit? ,' BNo
If yes, please list the information below. Attach additional pages if necessary.
unicipality Lic./Cert./Reg. #
n
pality Lic./Cert./Reg. #
Satus (Active/Expired/Suspended)
Status (Active/Expired/Suspended)
X Yes
CNo
752
Has the owner or operator ofthe proposed estrblishment ever held a body art
establishment license or Permit?
Ifyes, please list the information below. Attach additional pages if necessary'
State/lr4unicipality Lic./Cert./Reg. #Stah.rs (Active/Expted/Suspended)
State/lvlunicipality Lic./Cert./Reg. #Status (ActivelExpired/Suspended)
Town of Yarmouth trxes and lieng must be paid prior to rtnewal or issuance of your permits'
Please check appropriately if paid; Yes=-=-No
EMPLOYEE INFORMATION
Please list and s all Art Technicians lattoo erct nlice
Type ofBody Art
Performed
Employee Name
z
Crcdld.lD4l20
Requirementr for Body Art Esteblishment Permit
Submit the following to complete your application:
D A copy ofowner's valid identification card with picture
(state-issued licerse, passport, or military-issued lo)
tr Detailed ll,oor anrl operation plans ofproposed body art establishment (new epplicanb only)
I A copy of Blood Exposure Control Plan
n Proof of liability insurance / Workman's Comp. Insurance
! Client application and consent forms
! FirstAidandCPRcertifications
tr Medical Waste Rennoval Contract
! Bloodbome Pathogen Training
! Aftercarc information and instructions
Applicant Stattment of Consent
I undentand thet this permit is valid only in the Town of Yermouth and expires at the end of
the crle1dar ycar in which it wes irsucd. I also understand that atry notice to bc mriled to me by
the Town of Yarmouth Board of Hedth will be mailed to the rddress irdicated on this
application.
I hrve rtceived r copy of the Yatmouth Borrd of Hcalth Body Art Reguletions. I heve reed
snd ntrderstrtrd thc obligetions rnd rtquircments impooed upon a licenscd Body Art
Estrbtishment Owner/Operrtor by thoce reguletions, I also egree to compl;r with all of the
regulrtion rcquirements spccified in the Yermouth Boerd of Heelth Body Art Regulations
while prrc{icing in the Town of Yrrmouth.
I frrrther undentrnd thst it is my responsibility to ensure that individual Body Art Technicians
working in this estrblfuhment hrve r current vrlid Yermouth Board of Health Body Art
Technician License and comply with all spplicable health, safety, senitotion, sterilization, and
work prectices reguletions rs specified in the Yrrmouth Boerd of Health Body Art
Reguletions.
I hereby certify, under pcnehiec end prins of perjury, thrt to the best of my krowledge the
informetion pnovided on this appficrtion is complete end accurate rnd in no wey misrepresented.
N i chct lu Qauoc A
FulI Neme of Appliernt
t z-q
Ds
It is your responsibility to renew your permit at the end ofeach calendar yeer.
3
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