The URL can be used to link to this page

Home My WebLink AboutRichard DavisTIIE MMONWEALTH OF MASSACHUSETTS PERMIT NUMB ER: # 24 -0'7 5 TOW}[ OF YAR]VIOUTH BOARD OF HEALTH FEE: $55.00/ Technician This is to Certifu that Richard Davis at Spilt Milk HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE PRACTICE OF BODY ART (TATTOOING) This License is issued in conforrnity 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 [aws 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 3l , 2024 unless sooner revoked. lantary 1,2024, BOARD OF HEALTH:Hillnrd Bosktv, M.D., Clnirman Mnru Crais. ViceChairmon CharlesHolipnv, ClirkEic Weston Laurance Venezia, DVM (date) James G Director of Health Haltt Division TOWN OF YARMOUTH Boartl of H€alth l 146 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 02564-24451 Telephone (50t) 39b2231, qL 1241 Fat (50t) 76&'3472 Tvoc of Aodlcrrfun ENew FRenewal ApplicatiooFo{s):$160/Frcility $55/Tcchnicirn $55/Appratice Typ{s)ofBodyArt DTattooFacility lTanooTechician trApprentice tr Piercing Facility tr Piercing Technician ESTABLISIIMENT INFON"MATION 0u/< {8s B Name & Sffc Ilpo of orncnllp: tr Sole hoprietor tr Co'rporation tr Partnership $estabtisM is oumed by a corpor*ion, pqtnership, or other combinstiofl of individuals, please attach tle uanre, titlg tax ID#, d home address of all owners. E tltE6EEt Ogacr'r /TecDddur Nrnc: h /s First Middle Initial tl 73 Dat€TaxID 2_q V r lln ()Ltu br+q0t [0 -3 347 zip tast ) City State zip L.lo'l -CWl1 1 Phone 19 d,l u c'fted ll21h la iitli\ PRIOR LICENSURE Hes the owner or operator ofthe proposed esteblishment ever held a body art !99@p@ license or permit? If yes, please list the information below. Attach additional pages if necessary. pe"" trNo State/lvlunicipality Lic./Cert./Reg. # Zil t) ty Lic./Cert./Reg. # Status (Active/Expired/Suspended) Status (Active/Expired/Suspended) X Yes trNo Ees the owner or operator ofthe proposed establishment ever held a body art establishm ent license or permit? Ifyes, please list the information below. Auach additional pages ifnecessary. State&Iunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended) StateMunicipality Lic./Cert./Reg. # Status (Active/Expired/Suspended) Town of Yermouth taxes atrd liem mmt be paid prior to rtnewal or issuance of your pcrnits. Please check appropriately ifpaid: Yes_No EMPLOYEE INFOR]I'ATION Please list and all Art Technicians tce Type ofBody Art Performed Employee Name 2 Creatcd L2420 I Requirements for Body Art Establishment Permit Submit the following to complete yow application: tr A copy ofowner's valid identification card with picture (state-issued license, passport, or military-issued Io) tr Detailed floor and opemtion plans of proposed body art establ i shment (new applicants onty) I A copy ofBlood Exposure Contol Plan E Proof of liability insurance / Worknan's Comp. Insurance ! C1ient application and consent forms D First Aid and CPR certifications I Medical Waste Rernoval Contract n Bloodbome Pathogen Training E AftErcare information and instructions Applicant Stetcment of Consent I undentand thet this permit is valid only in the Town of Yarmouth and expires at the end of the calendrr year in whicb it wes issued. I also understand thrt any notice to be mailed to me by the Town of Yarmouth Board of Heelth will be neiled to the address indicated on this application. I have received a copy of the Yrrmouth Borrd of Health Body Art Reguletions. I hrve reed rtrd understmd the obligetions end rtqlrireDents imposed upon a licenscd Body Art Estrblishment Owner/Operator by those regulations. I also egree to comply with all of the regulrtbn requir.ements spccffied in the Yermouth Board bf Herlth Body Art Reguletions while precticing in the Town of Yrrmouth. I hereby certify, under peneltics and pains of perjury, thrt to the best of my knowledge the informatioa provided on this appHcation is complete and lccurlte and in no way misrepresented. Full Name of App[crnt flr s /zE Dste It is your responsibility to renew your permit at the end ofeach calendar yeer. 3 Signat6Ie Creded tD4no. I further undentrnd thrt it is my responsibility to ensure that individual Body Art Techniciars worhing in this estrblishment have a current valid Yarmouth Board of Health Body Art Technician License and comply with all applicable health, safety, sanitation, sterilization, and work.practices reguletions es specified in the Yarmouth Board of Hcalth Body Art Regulations. 'Z-.,V ./