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HomeMy WebLinkAboutRectify Barbershop & Beauty Alcove, LLC. 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit for Offering Tattoo or Body Piercing Permit Number: 4 This is to Certify that: RECTIFY BARBERSHOP & BEAUTY ALCOVE, LLC 90 COPELAND DRIVE MANSFIELD MA 02048 IS HEREBY GRANTED A PERMIT FORA BODY ART ESTABLISHMENT (TATTOO, PIERCING, AND MICROPIGMENTATION) This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires on December 31, 2019 unless sooner suspended or revoked. MANSFIELD BOARD OF HEALTH Michae[HeaCey, Chairman Town of Mansfield Town of Mame field - Board oj'Mealth 6 Park Row Mansfield, MA 02048 Application far Offering Body Art Services ESTABLISHMENT NAME: (/l. f-1 I ADDRESS: Cto— C CITY: _�� 4(± PHONE NUMBER OF OPERATION: NAME OF OWNER SWL a' t ADDRESS: c7l) Ski rL,'i I CJ CITY: fj')iv)*h STATE: r r tt ZIP: Uo rf3 STATE: {�i A ZIP: j7 a15"j PHONE NUMBER OF OWNER: EMAIL OF OWNER: C,IAi'tQl irn'1 NAME OF CORPORATION /ASSOCIATION/ RTNERS NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR MORE IN THE CORPORATION /ASSOCIATION! PARTNERSHIP: q(3 PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED WITHOUT PROPER CONSENT 12yrsrl� i5 peaur�� its tuck g i kLt/ Ctrl If; fir. rrc t. Qo [LI'A Lr CLsur' " �-ra '9 r �i e.e.-g MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: X11 s irin�l S'�. 01V�%Itrooj MR 0al��� TOTAL SIZE OF OPERATION IS: ADO()—FT. PROJECTED DATE FOR BEGINNING OPERATION: OR IF RENEWAL, RENEWAL DATE ku�_3 1 D ti 1 IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT Additional forms to be submitted: dent Application \,Informed Consent Form Drawing of the floor plan (n/a for renewals) v ,rnjury and/or Complication Report (blank) ,,.Disclosure Statement Exposure Incident Report (blank form) ,Infection Prevention and Control/ Exposure Control Plan and Employee Training Signatures Applicant Statement of Consent: 1 have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. c.111 § 31. a /a[LL Skc Camp Signature of establishment owner Date PrId name of establishment owner FEE: $200.00 rj CA \ Consent and Release Agreement for Micropigmentotion/ Cosmetic Tattooing This form provides information to make an informed choice of whether or not to undergo a micropigmentation application. This is a process of inserting pigments into the basal cell layer of the epidermis. Although semi- permanent this is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to. Although micropigmentation is effective in most cases, NO guarantee can be made that a specific client and using a pencil or powder may still be needed. We have no control over what occurs during the healing process. Generally, the results are excellent. However, a perfect result after one session is not a realistic expectation. It is usual and advised to expect a touch up after the healing is completed. Allow 4-6 weeks for healing time (healing time may vary) Initially the color will appear much more vibrant or darker in the first few days. The color WILL lighten 30-50% from the first visit, during the healing time. Usually within 5-7 days your brows and eyeliner will lose 10-15% thickness, soften and look more natural. The pigment is semi-permanent and WILL fade over time and will need to be touch up through the years. Touch ups are usually performed every 1 to 2 years. If you have had your eyebrows previously tattooed and are interested in a cover-up/re-work, we cannot guarantee results for cases such as these and we must approve that your eyebrows are workable during consultation. In some cases where the previous work is too dark, dense, or discolored, tattoo removal will be highly recommended before we begin the cover-up/re-work. Previously tattooed areas and cover-ups will almost always require additional appointments for best results. 02018 Rectify Barbershop & Beauty Alcove, LLC Possible Risks, or complications • Pain: There can be a certain amount of discomfort or pain even after the topical anesthetics has been used. Anesthetics work better on some people than others. • Possible side effects: Minor and temporary bleeding, bruising and swelling. This should dissipate within 1- 5 days. Some people bruise or swell more than others. Ice packs may help reduce swelling. Those who are prone to cold sores may develop one following lip procedures. Proper pre and post care will be advised. • Infection: Infection is very unusual but occasionally occur. Areas treated MUST be kept clean and only freshly cleaned hands should touch the areas. See "after care" sheet for instruction on care • Uneven Pigmentation: This can result from poor healing, infection, bleeding, skin type, or many other causes. Your Follow up appointment will likely correct any uneven appearance. • MRI: Pigments used in micropigmentaion contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or cosmetic tattooing. • Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, prilocaine, benaocalne, tetracaine, and or epinephrine are used. If you are allergic to any of these, please inform your technician. • Asymmetry: Every effort will be made to avoid asymmetry but our facial features may not be symmetrical so adjustments may be needed during the follow up session to correct any unevenness Client Sign Artist WO , Date ©2018 Rectify Barbershop & Beauty Alcove, LLC 2 ❑ 1 am 18 or older ❑ Aftercare instructions have been explained to me and a copy has been given to me. I will follow the aftercare to the best of my ability. I will call my artist if I have any questions regarding healing. ❑ 1 understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. ❑ 1 understand that any skin treatments such as Rentin A, Alpha Hydroxy, Glycolic Acids, laser hair removal, plastic surgery, and Botox or other skin altering procedures may result in adverse changes to my cosmetic tattooing ❑ 1 understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond your control and I will need to maintain the color with future applications. ❑ (Optional) I consent to Rectify Barbershop & Beauty Alcove to take and use before and after photographs for social media purposes. ❑ 1 understand that I will need more than one procedure to achieve my final goal. Touch- ups must be completed within 90 days of initial procedure in order to be considered a free follow-up. After 90 days touch-up fees will apply. ❑ 1 acknowledge it is not reasonably possible to my artist to determine whether I might have an allergic reaction to the pigments or ointments used in this process. ❑ 1 certify that I have read and understand the contents of this form. I understand the risks and involvement of this procedure(s). I have been given full opportunity to ask any questions I might have about the procedure. I authorize my artist to perform Micropigmetation on me today. Client Signa Date Artist Signature Date ©2018 Rectify Barbershop & Beauty Alcove, LLC Client Medical History Form Date Date of First Last City State/Province Zip/Postal Code Email Phone Number ®o you have or previously had any of the following: Check yes or No (all answers are confidential) History of MRSA YES NO Diabetes YES NO Allergic to metals YES NO Hepatitis A B C D YES NO Cancer YES NO Chemotherapy/Radiation YES NO Abnormal Heart Condition YES NO Alopecia YES NO Have you had any aspirin or blood thinners in the past week? YES NO History of cold sores? YES NO HIV YES NO Kidney Disease YES NO Pregnant or nursing YES NO Are you on any anti-inflammatories or steroids? YES NO History of skin disease? YES NO Have you had Botox in the past week? YES NO Please List oil Medication you are currently taking: The information provided is accurate and complete to the best of my knowledge, and that Rectify Barbershop & Beauty Alcove is not responsible for complications arising from incorrect Information. Client Sianature 02018 Rectify Barbershop & Beauty Alcove, LLC Please leave your brows alone for 48 hours. I have sprayed a liquid bandage on your eyebrows therefore they will be protected. It is ok to wash your face during these 48 hours but please don't get your cleanser on your eyebrows. After the 48 hours is up please follow the aftercare instructions as followed. Using your fingertips, gently wash the area with unscented soap (ex. Dove) morning and night, for 7 days. 1. Apply a very thin layer of the aftercare gel 1 have given you with a cotton swab 3 times a day for 5 days. 2. Avoid washcloths and scratching or picking at the tattoo during the healing process. (Healing time may vary) 3. Avoid hot tubs, steam rooms, public pools, long hot showers, sweaty exercise, or submerging the tattoo in water for the first 10 days. 4. Avoid direct sunlight or tanning beds for 2 weeks after receiving the tattoo. 5. Avoid putting makeup on the area for the first week. 6. Avoid facials, chemical peels, or microdermabrosion for 4 weeks. Immediately following your procedure, the tattooed area will appear to be darker and bolder in color and more sharply defined. This can last up to a week after the treatment while the initial healing process takes place. The treated area may feel a bit like sunburn afterwards but there should be minimal discomfort. The complete healing process takes about 6 weeks, at which time the true color of the tattoo is evident. During this process, your tattoo will soften and lighten. Be patient, even if you think too much color has been lost, as your skin is still regenerating and naturally exfoliating. Wait at least 6 weeks to see the true color, as it seems to take on new strength, and it is only after 6 weeks that your touch-up/adjustment can be done. If you have any questions please feel free to contact me at rectif�ail.com I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. 02018 Rectify Barbershop & Beauty Alcove, LLC 5 Temporary side effects from micropigmentation include but are not limited to: redness, swelling, Puffiness, bruising, dry patches and tenderness. You should expect to lose approximately 1/3 of the initial color during the healing process. We have selected the optimal pigments for you with this in mind. In approximately six days it may appear too light. After about 10 days, the color will show more. It will appear softer when completely healed. Day by day healing and what to expect Day 1. The eyes will be swollen and sore, like you have been crying, with a heavier eye makeup look. For the first 3-4 days, the color is darker than it will appear when healed. Apply a light gloss of Aquaphor ointment sparingly to the treated areas with a clean fingertip. Too much ointment makes the swollen area too wet. Use the ointment in the morning and evening. A third application is fine if needed, but don't over use. Clean the eyes in the evening with clean water and a tissue. Day 2. The eyelids are swollen for a few hours after waking up, still with heavier makeup look. When you wake up, refresh the treated area with cool water. Tissue dry and re -apply ointment. The eyes will be swollen and sore but will get better throughout the day. In the evening, gently cleanse with cool water, tissue dry, and re -apply ointment. Day 3. Swelling decreases but is not gone entirely. There is a tight feeling. The top layers of skin begin to lift away. The soreness will become less as the treated area begins to exfoliate. A rough texture appears on the skin. Use a small amount of ointment if needed. Day 4. There is a pinching feeling. Some itching is normal as the skin begins to flake. When the eyeliner area begins to exfoliate, do not pick at it! Discontinue ointment. It will flake off with the movement of the eye. Day 5. Color is somewhat grayish and will take a few more days to clarify to full color. The pigmented area begins to shrink and soften in size and color over the next few days. Exfoliation completes. The color will appear a bit "frosty," but will clarify in a few days. Day 6. The color has lightened from its initial overly -dark appearance. For the next few days, the color may now be lighter than what the final color will be. Day 10. The final color begins to stabilize and show through. The color will continue to soften as the healing process completes. I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. ©2018 Rectify Barbershop & Beauty Alcove, LLC 6 Lips pre-procedure: If you have any history of cold sores, fever blisters, or herpes simplex, you must contact your physician to obtain and take the proper prescription medication to prevent such outbreaks for at least 4 days before and after the procedure. Many physicians prescribe 12 capsules of 500mg Valtrex. Follow your physician's instructions • Apply ice for the first 2-24 hours to reduce swelling. e Keep moist with of Aquaphor ointment or Liprotek for the next 3-4 days, and then switch to lip balm or lipstick with an SPF of 15 or greater as the sun tends to fade lip color quickly. • Lips may appear to have too much color in the days following the procedure. You may add makeup to soften the color. ® Scars on the lips from fever blisters cause pigment removal. Day 1. Swelling, tender, heavy, thick lipstick look with reddish brick color. For the first few days, the color is darker than it will appear when healed. Day 2. Slight swelling, reddish, tender, with a slight metallic taste. Day 3. Less swelling, thicker texture, sore, hot feeling before exfoliation with an orange color. Day 4. Exfoliation begins, very chapped lips. The color will become lighter as the epidermis sloughs off. It will appear that you have lost all of your color, however, when your lips have healed completely, the dermal layer will gradually become darker. Day 5. Very chapped but almost finished with first chapping stage. Day 6. A soft, rich color begins to appear. Days 7-13 Lip color disappears and the "frosty" 2nd chapping stage begins as a whitish gray haze on the lips. Day 14. Color blooms from within more and more each day until day 21 (3 weeks post procedure). Day 21. Healing complete. The color you see is the color that you have. Your lips will remain a bit dry for a month or two. Use a good lip balm and they will return to normal with full color. I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. 02018 Rectify Barbershop & Beauty Alcove, LLC tmployews Keport or injury corm Instructions: Employees shall use this form to report all work related injuries, illnesses, or "near miss" events (which could have caused an injury or illness) — no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action. I am reporting a work related: Q Injury ❑ Illness ❑ Near miss Your Name: Job title: Supervisor: Have you told your supervisor about this injury/near miss? ❑ Yes ❑ No Date of injury/near miss: Time of injury/near miss: Names of witnesses (if any): Where, exactly, did it happen? What were you doing at the time? Describe step by step what led up to the injury/near miss. (continue on the back if necessary): What could have been done to prevent this injury/near miss? What parts of your body were injured? If a near miss, how could you have been hurt? Did you see a doctor about this injury/illness? ❑ Yes ❑ No If yes, whom did you see? Doctor's phone number: Date: Time: Has this part of your body been injured before? ❑ Yes ❑ No If yes, when? Supervisor: Your signature: Date: Supervisor's Accident Investigation Form Name of Injured Person Date of Birth Telephone Number Address City State Zip (Circle one) Male Female What part of the body was injured? Describe in detail. What was the nature of the injury? Describe in detail. Describe fully how the accident happened? What was employee doing prior to the event? What equipment, tools being using? Names of all witnesses: Date of Event Time of Event Exact location of event: What caused the event? Were safety regulations in place and used? If not, what was wrong? Employee went to doctor/hospital? Doctor's Name Hospital Name Recommended preventive action to take in the future to prevent reoccurrence. Supervisor Signature Date 2 Incident Investigation Report Instructions: Complete this form as soon as possible after an incident that results in serious injury or Illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness. This is a report of a: ❑ Death ❑ Lost Time ❑ Dr. Visit Only ❑ First Aid Only ❑ Near Miss Date of incident: This report is made by: ❑ Employee ❑ Supervisor ❑ Team ❑ Other Name: Sex: ❑ Male ❑ Female Age: Department: Job title at time of incident: Part of body affected: (shade all that apply) Nature of injury: (most This employee works: serious one) ❑ Regular full time ❑ Abrasion, scrapes ❑ Regular part time ❑ Amputation ❑ Seasonal - ❑ Broken bone ❑ Temporary t' ❑ Bruise Months with ❑ Burn (heat) this employer L3Burn (chemical) - ❑ Concussion (to the head) Months doing ❑ Crushing Injury thisjob: ❑ Cut, laceration, puncture ❑ Hernia ❑ Illness ❑ Sprain, strain ❑ Damage to a body system: ❑ Other 3 Nuattachments: mber of I Written witness statements: Photographs: Maps /drawings: What personal protective equipment was being used (if any)? Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details. Description continued on attached sheets: ❑ Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply) ❑ Inadequate guard ❑ Operating without permission ❑ Unguarded hazard ❑ Operating at unsafe speed ❑ Safety device is defective ❑ Servicing equipment that has power to it ❑ Tool or equipment defective ❑ Making a safety device inoperative ❑ Workstation layout is hazardous ❑ Using defective equipment ❑ Unsafe lighting ❑ Using equipment in an unapproved way ❑ Unsafe ventilation ❑ Unsafe lifting Cl Lack of needed personal protective equipment ❑ Taking an unsafe position or posture ❑ Lack of appropriate equipment / tools ❑ Distraction, teasing, horseplay ❑ Unsafe clothing ❑ Failure to wear personal protective equipment ❑ No training or insufficient training ❑ Failure to use the available equipment / tools ❑ Other: ❑ Other: Why did the unsafe conditions exist? Why did the unsafe acts occur? Is there a reward (such as "the job can be done more quickly", or "the product is less likely to be damaged") that may have encouraged the unsafe conditions or acts? ❑ Yes ❑ No If yes, describe: Were the unsafe acts or conditions reported prior to the incident? ❑ Yes ❑ No Have there been similar incidents or near misses prior to this one? ❑ Yes ❑ No What changes do you suggest to prevent ❑ Stop this activity ❑ Guam the hazard ❑ Train the employees) ❑ Train the supervisor(s) ❑ Redesign task steps ❑ Redesign work station ❑ Write a new policy/rule ❑ Enforce existing policy ❑ Routinely inspect for the hazard ❑ Personal Protective Equipment ❑ Other: What should be (or has been) done to carry out Description continued on attached sheets: ❑ Report Date Employee Last Name Primary Phone Number Position/Title Incident Date Supervisor's Name EXPOSURE INCIDENT REPORT FORM CSUCI Bloodborne Pathogen Exposure Program Employee First Name Alternate Phone Number Employee ID Number Incident Location Provide a description of the exposed employee's duties as they relate to the exposure incident: (Attach additional information, if necessary.) How did the exposure incident occur? Please provide an explanation of the routes(s) of exposure and the circumstances under which the exposure incident occurred: EMPLOYEE SIGNATURE DATE Send to Environment, Health, Safety & Risk Management Pflnt.FOYm And Control/ Exposure Control Plan In accordance with Mansfield Body Art regulations, a body art facility shall maintain and follow a written Infection Prevention and Control/ Exposure Control Plan (IPC -ECP), provided by the owner or established by the practitioners, specifying procedures to achieve compliance with the Mansfield Body Art Regulations. A copy of the IPC -ECP shall be filed with the Mansfield Health Department and a copy maintained in the body art facility. The body art facility owner shall provide onsite training on the facility's IPC -ECP to the body art practitioners and employees or individuals involved with decontamination and sterilization procedures. Training shall be provided when tasks where occupational exposures may occur are initially assigned, anytime there are changes in the procedures or tasks and when new technology is adopted for use in the body art facility, but not less than once each year. Records of training shall be maintained on-site for three years. The IPC -ECP shall be maintained current and updated whenever there are changes to any of the procedures or tasks listed and when new technology is adopted for use in the facility. Name of Body Art Facility: Rectify Barbershop & Beauty Alcove Site location : 90 Copeland Drive Mansfiled, MA 02048 Type of Body Art Facility: Micropigmentation Contact Person: Shalyn Gamba Telephone: Date of Plan Review Signature Page 1 of 7 Body Art Facility Infection Prevention and Control Plan A. Decontamination and Disinfection: Describe the procedures for decontaminating and disinfecting of workstation and surfaces 1. Workstation surfaces/countertops: All Work stations will be cleaned up by throwing away all items that can go into the waste basket. Any gauze with blood on them will be thrown out in the correct biohazardous can. Then the station will be completely wiped down with EPA germicidal wipes. 2. Workstation chairs/stools: All surfaces will be wiped down with a EPA germicidal wipes and new bed paper will be replaced for each client. 3. Trays: All Trays are to be disinfected with EPA germicidal wipes. All surfaces and legs are to be completely wiped down. 4. Armrests: All parts of the arm rest (under and over) are wiped down with EPA germicidal wipes. 5. Headrests: Wiped down with EPA germicidal wipes 6. Procedure area: Wiped down with EPA germicidal wipes 7. Tables: Wiped down from top to bottom with 2ermicidal wipes Page 2 of 7 8. Tattoo machine and Clip Cord: Machine is to be wiped down along with the cord with EPA germicidal wipes. Then wrap the machine and cord in a fresh wipe until next client. 9. Reusable instruments, calipers, needle tubes, etc. portable light fixtures or other: All reusable instruments are to be wiped down with EPA germicidal wipes as well as all portable light fixtures. B. Reusable Instruments or Disposable: Describe the procedures used for decontaminating, sterilizing, packaging and storing of reusable instruments. Include the procedures for labeling of sterilized peel -pack. Indicate whether the body art facility uses all pre -sterilized, single -use and disposable instruments. Describe the record keeping logs and procedure logs maintained on-site when using 100% pre -sterilized, single -use and disposable instruments. 1. Needle tubes: We do not use these items 2. Calipers: We do not use this item 3. Other instruments: The machine hand piece is to be wiped down and wrapped in a EPA germicidal wipe. The hand piece must stay wrapped for a minimum of 5 minutes before next use. The hand piece is to be stored in the marked covered plastic bin kept in designated cabinet drawer. We use all single use needles and hand tools. For every client, the needle and hand tool lot number, manufactured date and exp. Date must be recorded on clients consent form and filed away in designated file cabinet. Page 3 of 7 Body Art Facility Infection Prevention and Control Plan C. Storage: Describe the storage location and equipment used for the storage of clean and sterilized instrument peel packs to protect the packages from exposure to dust and moisture Storage for machine hand piece is a marked plastic container with lid. The container is to be stored in designated cabinet drawer. All disposable needles are kept in a marked plastic bin that is stored in cabinet. All Hand tools are kept in designated bins and stored in designated cabinet away from any moisture. D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing down the workstation for the following procedures Tattoo: perform hand hygiene. Put on protective equipment that is appropriate for the task. Cover the machine and machine cords with plastic coverings. Cover bottles used in procedure with protective plastic. Place bed paper over tattoo bed. Place barrier film on ring lights and parts of the cart that will be touched. Place all items to be used in the procedure on a set up area covered with clean dental bib (sterile needles, hand tools and other replaceable parts of the machine, pigment caps, gauze pads, paper towels, etc. ) Dispense pigments. Open the needle packages, hand tools and other sterile components in front of the client, and prepare the machine for applying permanent makeup. Don clean, previously unused, disposable examination gloves on both hands just prior to the procedure. Tear Down Procedure Remove needles from machine and hand tools and place them into the sharps container. Remove gloves. Preform hand hygiene. Give written and verbal aftercare instructions to client and answer questions. Don fresh gloves and breakdown work station starting from the least contaminated areas to the most contaminated areas. Pull edges of the dental bib on the setup area and roll up the contaminated surface to the inside, and place into plastic lined trash receptacle for proper disposal. Throw away bed paper into trash receptacle. Non-regulated biohazard wastes are safely handled and stored. Remove gloves and preform hand hygiene. Don fresh gloves and decontaminate the counter, table, or tray where the clean field was set up. Decontaminate client chair or table with EPA approved disinfectant that kills HIV, hepatitis and tuberculosis. Remove gloves and other protective gear. Wash hands with soap and water. 2. Piercing: N/A 3. Branding: N/A Page 4 of 7 Body Art Facility Infection Prevention and Control Plan E, Prevention of Cross Contamination: Describe the techniques used to prevent the contamination of Instruments, tattoo machines, trays, tables, chairs, clip cords, power supplies, squeeze bottles, inks, pigments, lamps, stools, soaps, procedure sites and additional areas of potential contamination during body art procedures. Include barriers provided to prevent cross contamination. Describe how procedure sites are prepared for a body art procedures. All instruments are covered with a protective barrier film, and plastic. Each surface used during the procedures are covered with sanitary bibs and bed paper. Each area that would be touched during the service will be covered with barrier tape. All Bottles used will be covered with plastic bottle bags (single use) only. All pigment bottles MUST be kept of the tray during procedures. Pigments must be poured into a pigment cup at the sink, away from any blood contamination. Body art procedures are performed as described in section D E. Sharps Containers: Describe the procedures used for the safe handling of sharps and indicate the location of the in -use sharps containers. Indicate disposal frequency for sharps waste. Once you are done with the needles and hand tools you must dispose of them inside the proper sharps container located on the wall. Once the gallon container has become full replace it with a new one and mail out the used container in designated mail back container. These items are sent to a facility designed for medical waste. F. Sharps Disposal: Describe the disposal of sharps used during a body art procedure. 1. Needles and needle bars: Each used needle is placed in designated sharps container that is placed on the wall. 2. Razors: Page 6 of 7 Body Art Facility Infection Prevention and Control Plan Razors are the be placed in the designated sharps container 3. Other sharps or single -use marking pens used on open skin: All other items that are single use are to be disposed of inappropriate sharps container G. List the Medical Waste Hauler, Mail -back System or Alternative Treatment Technology used for the disposal of sharps containers: Medical Waste Hauler: Street Address: City, State, ZIP: H. Sterilization of Jewelry: Describe the procedure used for the sterilization of jewelry prior to placing into newly pierced skin. We do not doi�ercing_ Sterilization room: Describe the procedure used for decontaminating Instruments prior to placing them into the autoclave. Indicate whether instruments are manually washed or machine washed, such as with an Ultrasonic machine. Describe the material used for soaking dirty instruments in the machine. We do not use a n autoclave, all of our hand tools are one time use. Machine base and hand piece are cleaned and wrapped in an EPA germicidal wipe. Scissors are tweezers are wiped with EPA germicidal wipes and then placed in sanitizing solution for 5 minutes. At the end of the day all J. Disinfection Products: List the disinfectant products used at the body art facility. Mckesson Germicid wipes, OPA matricide plus, Mckesson antimicrobial soap K. Time and Temperature: List the temperature of the autoclave and duration of time at that temperature required for the sterilization of clean instruments. Indicate where the sterilization log is maintained on-site. Page 6 of 7 Body Art Facility Infection Prevention and Control Plan Time: We do not use an autoclave Temperature: Psi: L. Personal Protective Equipment: List the personal protective equipment used during a body art procedure for the practitioner and the client. Gloves and face mask for practitioner. The clients are covered with a dental bib M. Handwashing Sink: List the locations of the hand wash sinks and describe the items supplied at each sink. Hand washing sink is installed in my room at the vanity. The sink is supplied with paper towels, antimicrobial soap and hand sanitizer. N. Aftercare Procedure: Describe the written recommendation and care information provided to the client after a body art procedure. List the type of bandages or wrapping provided after a body art procedure. Each client will be given an aftercare sheet for each procedure performed. Brow aftercare, eyeliner aftercare and lip aftercare. Please find each after care instructions in this packet. A liquid bandage is sprayed on the eyebrows after the procedure. Eyeliner and lips are protected with a barrier of auquafor. No bandages are needed. O. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when there is an accidental spill of sharps. If you encounter improperly disposed sharps in the work environment, handle them carefully. Keep your hands behind sharps at all times. Use a mechanical device to pick up sharps if they cannot be handled safely. Place the sharps back into a container and lock the lid. Wipe down all areas with EPA Disinfectant spray. Dispose of gloves and wash hands. P. Trash Receptacles and Disposal of Contaminated Trash: List the type of trash receptacles used and their location throughout the body art facility. Describe the procedure for the disposal of contaminated items, such as gloves. There are two different types of trash. One is located next to the sink and that is for general waste Page 7 of 7 Signature: Title Signature: Page 9 of 7 Body Art Facility Infection Prevention and Control Plan Date: Date: Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Practitioner's Permit for Offering Tattoo or Body Piercing I This is to certify that., SHALYN GAMBA Permit Number: 15 IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS located at: Tattooing Body Piercing Micropigmentatio RECTIFY BARBERSHOP & BEAUTY ALCOVE 90 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 11/20/2019 American Red Cross CPR/AED - Adult Certificate expires: 11/20/2019 Bloodborne Pathogens Certificate expires: 712 212 01 9 This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires onDecember 31, 2019 unless sooner suspended or revoked. MANSFIELD BOARD OF HEALTH 'vlichaeCHealey, Chairman C Toltvn of Mangield - Board o/eHealth Town of Mansfield 6 Park Row Mansfield, MA 02048 Practitioner rs Application fiv Of ing Beady Art Services OPERATOR NAME ac( -$n _.C%1�.Y,X%l r_ ,"lease afte h recent id ntificauon phofooraptr here (with heart and show'ders front Were,) aaproxi,nntol'y 2x3 in oes R size. Cletar photocopies are acceptable. -11 DATE OF BIRTH: � .. �� _ ` y Pru Ctre`ior r shaft be a rninirnunj of f 8 yP ars of age, 1 RESIDENCE ADDRESS: II, S� irl" STT... �7.� r� CITY: U.k r�.rbp _.. STATE: t r pl- ZIP: _..b aC MAILING ADDRESS: �ScL.r-r-l.'C. ccs 0.bbr2� CITY: STATE: ZIP: PHONE NUMBER OF OPERATOR: I a�j �S�SZO EMAIL OF OPERATOR: S r �� (� (�,{'Yl p� Ma �. C U77� PLACE OF EMPLOYMENT AS pA,PRACTTITIO�.JER: �Jp�e('�� ��D� ADDRESS: 9(D _(ICC"(}�A �.PC.'Y (�Lr� vc CITY: 1rn,l,Y�S'`fi7'[.1(.:\ r� STATE: 6r'`��Zip: -^� PHONE NUMBER OF ESTABLISHMENT: 1 / q. a cl y /3 _._ _... TYPE OF PRACTITIONER PERMIT APPLYING FOR: IChack c�U?hav apply) Tattooing E)Body Piercing Y Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: Jail. , IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Pleaseottach copies of appropriate docun'ienfation st Aid and CPR C;er0catrnns for tattoo and piercing American Red Cross Standard First Aid Certificate expires: American Red Cross CPR/AED - Adult Certificate expires: venting Disease Transmission andior Bloodborne Pathogen Training Bloodborne Pathogens Certificate expires: Course work /?rarn(rtg on hi,rrnan anatomy (body piercing only) Cowse arork;'training on skin diseases., disorders and = ondifions for taffoo and pro icing f ie,owitus B vaccination status or De u%inal;r't Nofif'catton Letter Evidence satisfactory to the Board of Health of at ie ist two (2a year's experience ience Prior experience of a cum.�lLtfi3d ar;proved epprc+l tr'esh;p ra grain p z r, r � ,>mas; Applicant Statement of Consent: I have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. 011 § 31. frac€itio, er perrrlas shall he vahil trorn the date of issuance and shaft expi c on the test day of the year of is sudr;ce unllpss r( -W f( C7 'Y f�Y it?C' Board, Date: FEE: $100.00 I'm declining to take the hepatitis B shot due to personal reasons. Sincerely, .. r ` O �� \\\ O O ci \ \ C\j { \ w ( y \ ) mmm Lm \ w * \If 3 \ \ ) ) 7 2 2 \ / \f \®Wx [ / \ y § \ 2 / ©-0 \ 6 e / / 3 2 { \ \ _ \ \ \ M M r-1 0 O � M rl c+ El o CO z O -0 00 8a;o 'D cam. .2 HJ ti d0 b R� r^ O W C14Ncd O4m4 4(R vi✓ 'd v� U Oti0 r -I b a > - ° cO ^^ � cd ) o m rCd- co O UWP (� N , a) •"" w O °�ho Cd � 4—)O — 0 CD -4� Cd4-4Ehi Q CO ' a p v Vf 0 O O O ca :c 78 O x78o O .r—j c U 'EM N � {M, z �d � Ln ~ �GOF�a TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name �a �-]g1L�D_ **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scott's Doctmients\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Contntomvealth of Massachusetts lf Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wtvw. inass.gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name Address: Phone #: / l '1 Are you an employer? Check the appropriate box: Business Type (required): I. Ep I am a employer with employees (full and/ 5. ❑ Retail or part-time)." 6.❑RestaurantBar/EatingEstablishment 2. r_1I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. E] Non-profit 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § I(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.K1 Other with no employees. [No workers' comp. insurance req.] c *Any applicant that checks box #1 must also fill out the section below showing theirworkers' compensation policy infomration. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an orgwrization should check box #1. I am an employer that is providing workers' compensation insurance for nev employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: N lJ ' {Ct I I ko of U Policy # or Self -ins. Lic. # (A 6 — 0 oz i5 14 a \oc Expiration Date: Attach a copy of the workers' compensation policy declaration page (slowing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi¢ations of the DIA for insurance coverage verification. Ido hereby ce ify, under thepains and peenallies ofperjury that the information provided Jabove is true and correct. 15, ' t7 . � ?['I , 11741 A1_1 DntP' / CK� j L t) ' / ) Phone #: Official use only. Do not write in this area, to be completed by city or torwu official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone DocuSign Envelope ID: 5BFBCE67-EDDi-4954-AADC-741BFD143CCA TRAVELERS) The Travelers Indemnity Company and Its Affiliates* `For the State of California the Travelers Company is Travelers Property Casualty CompanyofAmerlca Workers Compensation Insurance Proposal for: RECTIFY BARBERSHOP & BEAUTY ALCOVE, LLC FEIN 824998842 90 COPELAND DRIVE MANSFIELD, MA, 02048 For Policy Effective: Proposal Number: 09/01/2018 UB - 002L512269 thru 09/01/2019` Proposal Presented By: PAYCHEX INS AGENCY INC 150 Sawgrass Dr Rochester, NY, 14620 800 4720072 — DocuSign Envelope ID: 58FBCE67-EDDi-4954-AADC-741 BFD143CCA ACORD WORKERS COMPENSATIONAPPLICATION °^`H 08-10-2018 _- fOOUCHft [pIryANP IMDBft IYAI(HR Bm TRAVELERS(P&C) UB —0021-512269 ^PP„G,,,, Rectify Barbershop & Beauty Alcove mTB NeT AADRAS: Paychex Insurance Agency, Inc. LOC NDIH CODE PROPOSEDEM"M 150 Sawgrass Drive PROPOSED VP DATE NORMALANNWEMANYRATINGOATE PARTICIPATING NON Rochester, NY 14620- RETRO PUN MING 90 COPELAND DRIVE MANSFIELD, MA, 02048 09/01/2019 nmlmM $ 50,000.00 0.29 $ 145.00 mvah� PARTMIPATIND MY IS arc PARTR- EMPLOYER'S LIA8NTY PART S. OTHER STATES INS OEDUCT0LE8 AMOUNTM OTHERCOVERAGES COMPENSATOR (eta.) $ 500,000'00 rNnrvmruc ..T1111 j( LB,rrzan cow' PAASNRAKITP SV8CH9PJFA'SCQV MffEP: /De: 9OB CODH: CRBDHT MEDICAL rD NVAlBAA: :PNCI'IMMI/BAID USLRN. ry,➢BRAL PAfPLO)ER/D NV)IBHR NLU'(ION(ALBHR OS/IM RAIA'O BVACi UID OR BfATH 82-4998842 Bea D/aR RHon unoxry miseR TATUS OF SUBMISSION BILLING/AUDIT INFORMATION MOTE I X ISSUEPOLICY SILLNGPUN PAYNtiNTPUN AUDIT BOUND(GNe &tevnd/rc envN wp/) x AGENCY SILL ANM/AL rOTIAER ATE"IRATION MONTHLY _ ASSICNEDRISKI&I,i0ACGRM&A SEMI-ANNUAL SEMI-ANNUAL OTHER: UAATPHY OCATIONS 90 COPELAND DRIVE Mansfield MA 02048 OLICY INFORMATION LOC CUBS CODE CODE PROPOSEDEM"M SF OYMB HULL PART PROPOSED VP DATE NORMALANNWEMANYRATINGOATE PARTICIPATING NON 1A RETRO PUN 19/01/2018 09/01/2019 $ 50,000.00 0.29 $ 145.00 PARTMIPATIND PARTLWORKERS PARTR- EMPLOYER'S LIA8NTY PART S. OTHER STATES INS OEDUCT0LE8 AMOUNTM OTHERCOVERAGES COMPENSATOR (eta.) $ 500,000'00 MANAGED $ EACHACGDENT MEDICAL 'ECIFY ADDITIONAL COVERAOESIENDONBENEMT8 See Carrier quote for premium detail USLRN. FACTORED PREMIUM CAREOPTION $ $ 500.000.00 OIREA56PoLICYLIMIT WCREASEOLIMITS $ NDEMNITY 5 VOLWITARY COUP EXPERIENCE MODIFICATION $ $ 500.000.00 DISEASEEEACH EMPLOYEE $ tow CONSTANT § ASSIGNED RISK SURCHARGE FOREIGN COV ARAP NOENOPLAN/BAFETYCRMP ADDITONALCOM1PANYINFORMATON $ PREMILMOISCOUNT 5 EXPENRECONSTANT $ ATING INFORMATION 5 IIIMUMPREMIUM $ OEPOSITPREMIUM $ $ / 'f 5.R 'ATE LOC CUBS CODE CODE CATEGORIES, DUTIES, CUSdpCATIONB SF OYMB HULL PART ESTIMATED ANNUAL REMUNERATION RATE ESTIMATED ANNUAL PREMUM 1A 1 9586 Barbershop $ 50,000.00 0.29 $ 145.00 'ECIFY ADDITIONAL COVERAOESIENDONBENEMT8 See Carrier quote for premium detail FACTOR FACTORED PREMIUM TOTAL $ WCREASEOLIMITS $ DEMCTS[E 5 EXPERIENCE MODIFICATION $ tow CONSTANT § ASSIGNED RISK SURCHARGE § ARAP 3 $ PREMILMOISCOUNT 5 EXPENRECONSTANT $ 5 IIIMUMPREMIUM $ OEPOSITPREMIUM $ $ / 'f 5.R TOTAL EST ANNUAL PREMIUM $ $ 359 00 1UKWIJUJzUUVA/UI PLEASE COMPLETE REVERSE SIDE A ACORD CORPORATION 1990 Rep: OFvIA Varum Mansfield Body Art Establishment Inspection Form Name of Establishment: Address of stablishment: C7 Tel.# ( ) Establishment Owner -11C ) Name(s): (� Time: (zk'aLA\ Owner(s) Addres . Begin: —am Cprt C\\\ Tel.# (' t ) CSS S W Inspector Name: �Yh �cnnc�ucx��vVeP� Inspection Date: Time: (zk'aLA\ Begin: —am Cprt End: —am —pm Type of Establishment: — Tattoo — Piercing — Tattoo and Piercing _.Ix Micropigmentation Reason for Inspection: r�\ Pre -Operative Inspection — Annual Inspection 1 — Complaint Investigation — Injury Report Investigation Key: Violation column: Viol Corrected column: Reinspection Date: Inspector "X" indicates a violation of the Body Art Regulations "✓ " indicates compliance with the Body Art Regulations "✓ " indicates compliance with the Body Art Regulations upon reinspection of the violation. Date when violation was noted as being in compliance with Body Art Regulations. Viol Reinsp LEGULATION VIOLATION COMMENTS Corrected Date Posting: Postings are prominently displayed Disclosure statement W�\ Name, address and phone number of / BOH Emergency plan: W & PCfi� n o e -police, fire, EMS contacts -working employee/client phone Occupancy permit y�S Valid establishment permit v. Cce�� Valid practitioner(s) permit(s) W �`� Wig CeCzw� Recordkeeping: (kept for 3 year minimum) Records accessible to BOH Establishment Information: \S -name,address, Ins. of operation -body art procedures -inventory list (jewelry, instruments) -MSDS and Body Art Regs Employee Information ti ft -name,address, tel #, DOB -exact duties -practitioner hepatitis B info Client Information u L syzvv� m5 -name, address, DOB -date, type, location and practitioner of procedure -health history and consent form -copy of guardian ID Autoclave manufacturer's instructions available Monthly autoclave spore destruction tests available Physical Facility- Overall: Walls, floors and ceilings smooth and clean Establishment space -separate from non -establishment space �` S (e.g, habitable areas) Viol Reinsp REGULATION VIOLATION COMMENTS Corrected Date Physical Facility- Overall: (cont'd) Client waiting area -separate from body art procedure areas No animals except: - service animals / -fish aquariums in non -procedural areas V Free of insect and/or rodent infestation Adequate ventilation Adequate lighting —20 foot candles 3 feet off floor Toilet room (1 at minimum): -toilet -sink with hot/cold water under pressure / -toilet paper, liquid soap, paper towels v/ in fixed dispensers -waste receptacle: covered, foot operated. Solid waste: -stored in covered, leak -proof, rodent resistant containers ✓ -removed weekly at minimum Janitorial sink -adequate size -hot/cold water under pressure Instrument cleaning area present: -autoclave area at least 36 inches from Y1 I ultrasonic clewing unit Instrument storage area -clean, dry, covered containers r -secure area; instruments only Physical Facility- Procedure Area: Procedure surfaces smooth, easy to clean and sanitize Client chairs/benches, easy to clean and sanitize ✓ 45 sq. feet per practitioner Viol Reinsp REGULATION VIOLATION COMMENTS Corrected Date Physical Facility- Procedure Area cont'd: Dividers between work stations VZ Adequate lighting -100 foot-candles: procedure level, sharp / and instrument assembly level Hand sink at each station -hot/cold water under pressure -liquid soap in fixed dispenser -disposable paper towels in fixed dispenser Waste receptacle: -covered, foot operated -emptied daily No practitioner smoking, eating, or drinking Single Use Items: All products applied to skin are one client use and disposed o£ - hollow bore, needles with cannula -stencils, gauze, razors, etc. - ink, dye, pigment and individual containers Sharps disposed into approved sharps container Sanitation and Sterilization: Ultrasonic cleaning unit present and working r^ Autoclave present and working, if non- ' 6, disposable instruments are used Autoclave is: -clean -located away from workstations and public areas Non -disposable instruments are: - Cleaned, processed in ultrasonic unit - packed individually in sterilizer packs sterilized by steam autoclave Sterilizer packs have: - temperature/sterilizer indicator - expiration date- not exceed 6 months. Viol Reinsp REGULATION VIOLATION COMMENTS Corrected Date Sanitation and Sterilization cont'd: Sterilizer packs intact, no breach v� c Disposable medical gloves available Practitioners wear gloves for handling / instruments Standards of Practice: review with Practitioner(s)) Practitioners perform body art procedures according to CDC Universal Precautions. Practitioners: -maintain personal cleanliness, wear clean clothes, -are free of skin rash or infection Practitioners refuse service: - clients under the influence / - tattooing, branding, scarification of clients under 18 yrs. Ear piercing systems used on car lobe r e` only. Practitioners wash hands with hot water and soap prior to glove application/ procedure. Practitioners wear single -use gloves during procedure: -gloves changed when torn or contaminated Instruments contaminated during procedure are replaced immediate! Client skin preparation: -free of visible infection -cleaned V/ Practitioners use inks, dyes, pigments, needles, all other equipment: / -manufactured for body art procedures only -according to manufacturer's instructions Aftercare instructions provided to client Additional comments: Additional comments: