HomeMy WebLinkAboutNicholas JohnsonTHE COMMONWEALTH OF MASSACHUSE
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: # 24-07 6 FEE: 555.00/ rechnician
This is to Certifu that Nicholas Johnson
at Soilt 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 subiect to the provisions ofihe Laws ofthe
Commonwealth ofMassachusetts relating thereto, and upon such terms and coiditions, 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.
Januarv 1.2024. BOARD OF HEALTH:
(date)
Hillard Bosl<ev, M.D., Chnirman
Maru Crais, Vice Anirman ChnrlesHoli,av, 1erk
Enc Weston
Laurance Venezia, DVM
James G.
rh
TOWN OF YARMOUTH
l 145 ROUTE 2& SOUTH YARMOUTH, MASSACHUSETTS 02654-24451
Tcbptronc (50t) 39E-2231'e,xt" 1241
Fs (50E) 76G3472
Board of
H€.lrh
Hcaltt
Division
Avno of Aldicrlbl
oNew fl Renewal Applicatim Fo{s): $160 / Frciltty $55 / Tcchnictu $5ll / Apprutice
Typ{s) of Body Art: D Tattoo Facility
E Pi€rciry FaciiitY
ESTAELISHMENT INNOR}IATION
Sniit r\AlL q6 u/< ,/80
gusffiNameE
b
Tlpc of orncnhtp: tr SoIe hoprietor tr Corrporation D Prtncrship
If establbhcff is ovned by a corporaion, portnenhip, or other combinstiol of individuals' please
attach tlo name, title; tax ID#, ard home address of all owneis.
Ertrtfrtnout Ownor'r llcc.Lddeu Nrne:
Ali 0la s )rt hns o n
First iast Middle Initial
Date Tax
f fattoofectnicia D APPrcntice
rl Piercing Technician
(ws
AS ,0t 113_sq Z
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q n h
1
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Chd l24ZD
PRIOR LICENSUR,E
Heg the owner or operator ofthe proposed esteblisbment ever held a body art
!gq@ig@ license or Pemit?
lf yes, please list the information below. Attach additional pages if necessary.
r@""
trNo
State/lvlunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
04-LI /4-
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or Permit?
ijyes, ptease list the information below. Attach additional pages if necessary'
E Yes
trNo
State/Ivfuoicipdity Lic./Cert./Reg. #Status (Active/Expted/Suspended)
StateMunicipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
Town of Yermouth taxes and liens Eust be paid prior to renewll or issuance ofyour permits'
Please check appropriately if paid: Yes=- No
EMPLOYEE INFOR]V'ATION
nticePlease list and s Art Technicians erctt
Type ofBody Art
PerformedEmployee Name
2
Cred.d 1D4D0
all
Requirements for Body Art Esteblishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification card with picture
(state-issued licerse, passport, or military-issued to)
tr Detailed ll,oor ""d operation plans of proposed body art establishrnenl (new rpplicrrb only)
I A copy of Blood Exposure Conhol Plan
! Proof of liability insurance / Workrnan's Comp. Insurance
I Client application and consent forms
! FirstAidandCPRcertifications
E Medical Waste Removal Contract
! Bloodbome Pathogen Training
n Aftercare information and instructions
Applicant Statemtnt of Consent
I understend thrt this .permit is valid on$ in the Town of Yermouth and expires at the end of
the calendar year in which it wss bsued. I also understand that any notice to be mailed to me by
the Town of Yrrmouth Board of Heelth will be nailed to the address indicated on this
application.
I hrve rcceived r copy of the Yrrmouth Bord of Herlth Body Art Reguletions' I hevc reed
urd utrdeBtrDd thc obligetions end rtquiremcnts imposcd upon a licenscd Body Art
Estrblfuhment Owner/Opcrrtor by those reguletions. I elso egree to comply with all of the
regulrtbn requirements specified in tho Yermouth Board of Health Body Art Regulrtiors
while prrcticing in the Town of Yrrmouth.
I further understrnd thet it is my responsibility to ensure thst individual Body Art Technicians
wor*ing in this estrblilhment have a current valid Yermouth Board of Health Body Art
Technicien License and comply with dl applicable health, rafety, srnitrtion, sterilizstion' and
work prectices reguletions as specifred in the Yermouth Board of Health Body Art
Regulations.
I heruby certify, under pendtica rnd prhs of perjury, thet to the best of my knowledge the
informrtiol provided on this appHcetion is complete rnd accurete and in no way misreprerented.
Nicho la s ,)th n,ron
FuIl Name of A t q I Zq
Date
It is your responsibility to renew your permit et the end of each calendar yeer.
3
rgne re
Creacd t/24l20