HomeMy WebLinkAboutSean SheaTHE COMMONWEALTH SAC USETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FEE: $55.00/ Technician
This is to Certiry that S(]an Shca
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 to the Board of Health, by Chapter 140,
Sections 51, ofthe General Laws, and amendments thereto, and is subject to the provisions ofthe l-aws ofthe
Commonwealth ofMassachusens relating thereto, and upon such terms and conditions, and to the rules and
regulations in regard to the carrying on ofthe occupation so Iicensed as adopted bythe Board of Health, and
expires December 31. 2024 unless sooner revoked.
Januarv 1.2024. BOARD OF HEALTH:Hillard Bosketl, M.D., Chnirman
Maru Crnis. Vice Chnirman ChnrlesHoli,av, Clirk
Eic Weston
Laurance Venezia, DVM
(date)
James G
Direc Irh
PERMIT NUMB ER: # 24-0'7 7
TOW N OF YARMOUTH
I 146 ROUTE 28, SQUTH YARMOUTH, MASSACHUSETTS 0266/-24451
?elePhone (50E) 39E-2231, ext. l24l
Board of
Health
Health
Division
Fax (50E) 760-3472
Tvpe of Aoolicrtion
E New fl Renewal Applic*ion Fee(s): $150 / Facility $55 / Technician $55 / Apprentice
/fattoofectnician tr APPrentice
tr Piercing Techniciut
0u/< {8
Type(s) ofBody ArI tr Tattoo Facility
tr Piercing FacilitY
ESTABLISHMENT INFOR,MATION
s
B Name &
7
ty State zip
Typc of owncnhip: tr Sole Proprietor tr Corporation n Partncrstdp
If establishment is owned by a corporation, partnership, or other coobination of individuals, please
attach tho name, title, tax ID#, and home address of all owners'
Estobllshment Owner's / Technicisnr Name:
C
First Last Middle Initial
Birth Tax ID # (establishment enly)
rnL 7qeq 0
City State zip
Email
C.tdrn lD4D023
FIB IJ U 2024
HEALTH DEPT
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L,I
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PRIOR LICENSUR-E
Has the owner or operator ofthe proposed establishment ever held a body art
!q[i9!4 license or permit?
ease ist the tion below. Auach additionalpages if necessary.
cipality Lic./Cert./Reg. #S
*es
trNo
Slatus (Active/Expired,/Suspended)
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
E Yes
trNo
Has the owner or operator ofthe proposed establishment ever held a body art
establishment license or permit?
Ifyes, please list the information below. Attach additional pages ifnecessary.
State/Municipality Lic./Cert./Reg. #Status (Active/Expired/Suspended)
State/Municipality Lic./Cert./Reg. # Status (Active/Expired/Suspended)
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits.
Please check appropriately ifpaid: Yes
EMPLOYEE INFORMATION
Please list and s ct ctll B Art Technicians taltoo.tercln tce
Employee Name Type ofBody Art
Performed
2
Crc cd lD4D02i
No
Requirements for Body Art Estsblishment Permit
Submit the following to complete your application:
! A copy ofowner's valid identification card with picture
(state-issued license, passport, or military-issued to)
! Detailed floor and operation plans ofproposed body art establishment (new applicants only)
n A copy ofBlood Exposure Control Plan
! Proof of liability insurance / Workman's Comp. Insuance
! Client application and consent forms
! First Aid and CPR certifications
tr Medical Waste Removal Contract
! Bloodbome Pathogen Training
tr Aftercare information and instructions
Applicant Statement of Consent
I understand that this permit is valid only in the Town of Yarmouth and expires at the end of
the calendar year in which it was issued. I also understand that any notice to be mailed to me by
the Town of Yarmouth Board of Health will be mailed to the address indicated on this
application.
I have received a copy ofthe Yarmouth Board of Health Body Art Regulations. I have read
and understand the obligations and requirements imposed upon a licensed Body Art
Establishment Owner/Operator by those regulations. I also agree to comply with all of the
regulation requirements specified in the Yarmouth Board of Health Body Art Regulations
while practicing in the Town of Yarmouth.
I further understand that it is my responsibility to ensure that individual Body Art Technicians
working in this establishment have a current valid Yarmouth Board of Health Body Art
Technician License and comply with all applicable health, safety, sanitation, sterilization, and
work practices regulations as specified in the Yarmouth 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 complete and accurate and in no way misrepresented.
,kon Shm-
Full Name of Applicant
Zlrl
Date
It is your responsibility to renew your permit at the end ofeach calendar year.
3
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Crcated 1D412023