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Art & Soul Tattoo, LLC - 12/31/019
Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit or O ' f Offering Tattoo or Body Piercing - -- Permit Number.' 2 This is to Certify that: ART AND SOUL TATTOO, LLC 88 COPELAND DRIVE MANSFIELD MA 02048 IS HEREBY GRANTED A PERMIT FOR A 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 MichaeCHeaCey, Chairman Town of Mansfield Town 6 Park Row of Mansfield - Board of Health Mansfield, MA 02048 Application for offering Body Art Services ESTABLISHMENT NAME:_ ----- ADDRESS: 88 CITY: MftCNS ( G _ STATE: ZIP: D_/1 LW-- PHONE NUMBER OF OPERATION: NAME OFOWNER yAp,W !k ADDRESS:��hJ CITY: OkNSTATE�:LMA— ZIP: 0'24 -044 PHONE NUMBER OF OWNER:Q �'_'"� Litt EMAIL OF OWNER:�.�/..an NAME OF CORPORATION / ASSOCIATION I PARTNERS NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR MORE IN THE CORPORATION / ASSOCIATION I PARTNERSHIP: PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED WITHOUT PROPER CONSENT c% l N1uL5i b� v�L,l�d avLd 1pres�t ;dam ��redt�v�� --- MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: �8 Gp }��r✓-�N D �D � M�Ns �-�,LD tet"_, � —_ o �— TnTAI SIZE OF OPERATION IS: '%�j �i FT. PROJECTED DATE FOR BEGINNING OPERATION: IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT Additional forms to be submitted: Client Application Informed Consent Form Drawing of the floor plan (n/a for renewals) Injury and/or Complication Report (blank) OR IF RENEWAL, RENEWAL DATE I /I /y L' I - Disclosure Statement Exposure Incident Report (blank form) Infection Prevention and Control/ Exposure Control Plan and Employee Training Signatures Applicant Statement of Consent: I have recieved and read a copy of the Town of Mansfield pBoard of Health Regulations for Body Art and understand the requirements of these regulations. I herebyapply 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. Signature of establishment owner Date FEE: $200.00 A"A N. -Mit C�6 e-0e�v- Print name of establishment owner Body Art Establishment Infection Prevention 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: ALT 56vO, -PA-j---FOO Site Address: ST City, State, ZIP: V Type of Body Art Facility: Contact Person: 41 �j A- Date of Ph Signature Page 1 of 7 WC 41 Telephone: y�0� 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/counter tops: Wl -eS or to �-eqc-H vtx•i Av`e 2. Workstation chairs/stools: 3. Trays: It 11 4. Armrests: It H 5. Headrests: tl +I 6. Procedure area: I, +I 7. Tables: ++ II Page 2 of 7 Body Art Facility Infection Prevention and Control Plan Tattoo machine and Clip Cord: "HB wIPEFS or BLEACH- Mt-CTuee� 9. Reusable instruments, calipers, needle tubes, etc. portable light fixtures or other: HS WIPES, .NEI -P LE- 7u6ES AV- F_ VISC6SA13t_E-,--P Gl✓-1> I� �,10--TtaAS}-E• 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: 1?>" PV�CrtcV_s AV—Ir USa--D. As STATED A P' DVE T. 5TA-1NvFSS STE_�aI_ rugs tet= soArKCU t�) Et rN�R 13 St��vi Up- A, woX THeh1 l2uBT3J D 'TI buK�oUE�V t LY, bP ISD A I f2�,'PL/�1 D I rJ DA�TF_tD P ew P 2. Calipers: i/A, -�Q MON T ftL—Y /V,0,/1J VT0 P—E p L_1zE fR 3. Other instruments: /\j %Pr 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 ALL SUP pu E=S OrfZr STar? D W CAR II F_ --F& Page 3 of 7 Body Art Facility W66tion Prevention and Control Plan D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing down the workstation for the following procedures Tattoo: ��ovES Pt?r-, vvD9N -To 5F_'up AV-t,A.bP-OP c-LOTHA-AGI:D lou ApppoPP-lATE PLC MY ASA INGwbT�S ; ')(3 Ct, b15rl��p �OTIoN,SING�(�G l,l 2. Piercing: N/A 3. Branding: N)A 1NK CA-V�>, Ir,/ K, t5 EXGFiP7 sDAP -+' CL_ L -)- til: Di-eS IuL3'f pLAGEt> IN 1310- rf?AS{ ( ^-rFDo SOAP 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. L- -DyF—S A -W -E V\ld i N -+" P-:P,"VZ-(F-2 LF- d '17)UG�-I NCq- A NULb N C2 IS SUT 4' P_Cc-&D A—F—A -C -TAT o O ykti, l S wig. P o v 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. CIES i3 t - 60X�s ALL LOCATED W LA—C-t S IN L -ML Y AJL�- - tCLADLLM W H F -D W d -E Page 4 of 7 Body Art Facility Infection Prevention and Control Plan F. Sharps Disposal: Describe the disposal of sharps used during a body art procedure. Needles and needle bars: CALF�C-L'l V(AK D IN LL—LOX 2. Razors: /( // B/p—Toel- s1 3. Other sharps or single -use marking pens used on open skin: Qlo - 7%2,S/Y G. List the Medical Waste Hauler, Mail -back System or Alternative Treatment Technology used for the disposal of sharps containers: Medical.Waste Hauler: "CID WlqSTG zi/S/�Ds 9 L, /A)C Street Address: P• L/) • OO X 3 :2 - City, State, ZIP: n • IV"q' UZ 35 r 7v- X12-- b /Do H. Sterilization of Jewelry: Describe the procedure used for the sterilization of jewelry prior to placing into newly pierced skin. WIq 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. ULTtZASM,4C IS aSF—D v1- SCP'-a6k, a/AJ J. Disinfection Products: List the disinfectant products used at the body art facility. H6, 14) )PES/ 13l.-elC-/f Page 5 of 7 Body Art Facility Inf6ctiontPrevention and Control Plan 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. Time: 2, 0 MIN S Temperature: Psi: 2 Sp L. Personal Protective Equipment: List the personal protective equipment used during a body art procedure for the practitioner and the client. r?p.,<1CTtTfDN;�-12_� �oLoV�S GLI P—I,JT BANDAGE— AFTEN2- Tf�-T-0Q M. Handwashing Sink: List the locations of the hand wash sinks and describe the items supplied at each sink. so"n,p -+ t-tOT w�Tr a rN INDI V 17UA-U So�UV� tdP-uS�-FCS . 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. 5�� ENC�OSCD R�T�cAe)-(SRN1-P�17S,b�t3-GLOT�}S CJ2 PLAST(C WPA-P tS uSFc) i7 -6e- fa�lNb/�G w�Ci GTf{- Wl� O. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when there is an accidental spill of sharps. IF 1l�lS � i PC'EN( D- CoO��S 'I ++B y"O&S wtLL j3E LASED Ta C�-Lf—�AN A-1--(=�C—G`TED AYL 1. 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. �Lovr=S Ai2E PLACE -D IN 2>to—T(2ASH IF cG/\JT/-'k(VmVC',TP-:D w(T+- 3l -CLOD &FMIE✓e? G--F—AN iNC, &LOVES 6a IA/ (EGULAI2 T2 -AS �A , A -LL i"TACL-GS FkAt,-- LIDS ONE IS IN fC--/- 7(-- 4 i?-Dd/V\. IS sToe-ED rlv U(-' /V\'C) NT -E l�Y Op- /95 N �t✓o . Page 6 of 7 Body Art Facility Infection Pteventiori and Control Plan Q. Negative/Failed Spore Test: Describe the procedure conducted when a monthly spore test has failed. Indicate where the facility maintains a spore test log on-site. SMS G,�-`121-8 I M M L'%7� I �7� -�. /9- c 4LL es %- 2CPI,9-�2 FACILiTy 10 -MED `Il -FY 02( VIOL ,q R. Commercial Ink or Pigment Manufacturers: List the manufacturer(s) for the inks or pigments used at the facility. Describe the procedure for dilution of inks. Only sterile water should be used for dilution of inks or pigments. W r— /lU.L f3,E-7 I7s /.ti -nq— Sagp 19S wLL7LZ. S. Service Animals: Describe the facility's policy regarding service animal presence in procedure, decontamination, and sterilization areas. I DON IT L-19 EF /T- 6WF iiJo Cffv/'ci�F-41ul 4t- 1 S Oa -r7-,,,4 T6512E IF /T FEES /T SITS /q -S -F/q(2 qS DSS/1�'L Maintain a copy of this completed document in your files. Submit one copy to the Mansfield Board of Health. I hereby certify that all body art practitioners performing body art at this facility and employees or individuals involved with decontamination and sterilization procedures have been trained with the procedures pd information contained in this document. To the best of my knowledge and belief, the statg ne is made herei�are rcprrect ang1rue. Title: (/W!/I Piles/iT/ K �l S Date: �� 2 I For Body Art Practitioners practicing at the establishment: I hereby certify that I have been trained with the procedures and jnforrnetion contained in this document. To the best of my knowledge and belief, the, atetempr is made herein are correct and true. Signature: _ w. Title: rit, 41 U,_ Date: Signature: Title:__4 f 1 S� u Date: Page 7 of 7 Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Practitioner's Permit for Offering Tattoo or Body Piercing This is to certify that: ANNA N. MICHENER Permit Number: 4 IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS located at: Tattooing Body Piercing Micropigmentatio ART AND SOUL 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 112012021 American Red Cross CPR/AED -Adult Certificate expires: 1120/2021 Bloodborne Pathogens Certificate expires: 1/2012021 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 michaeCHeaCey, Chairman Town of Mansfield Town of Mansfield - Board of'Health 6 Park Row Mansfield, MA 02048 Practitioner's Application for Offering Body Art Services X II , 7N'- OPERATOR NAME: please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. '(Aj^practitfonershall be gmiAnimum of 18 years of age.) DATE OF BIRTH: 12 2-"7 RESIDENCE ADDRESS'`J-od CITY: "art J �Z� STATE: /UlAd— ZIP: MAILING ADDRESS: `sA.km-p— CITY: y ` fi /STATEN ZIP: PHONE NUMBER OF OPERATOR: "> 0 0 3 r - /�/ I � EMAIL OF OPERATOR:OS �v/�/Z �I�GC� PLACE -OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: f, �S CITY: �� l� S(T'ATE: ZIP: PHONE NUMBER OF ESTABLISHMENT: 5 — 3 — TYPPRACTITIONER PERMIT APPLYING FOR: (Check all that apply) Tattooing [3 Body Piercing Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Please attach copies of appropriate documentation First Aid and CPR Certifications for tattoo and piercing American Red Cross Standard First Aid Certificate expires: A ion crncs CPRtAED - Adult Certificate expires: Preventing Disease Transmission and/or Bloodborne Pathogen Training Bloodborne Pathogens Certificate expires: Course work /training on human anatomy (body piercing only) Course work /training on skin diseases, disorders and conditions for tattoo and piercing Hepatitus B vaccination status or Declination Notification Letter Evidence satisfactory to the Board of Health of at least two (2) years experience prior experience or a completed approved apprenticeship program (n1a forrenewals) 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. 1 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. Practitioner permits shall be valid from the date of issuance and shall expire on the last day of the year of issuance unless revoked oner hy the Board. _2- Signatur e FEE: $100.00'"�`� �\ IIIL vVIIt//iVN IYGNIt/t f t11 NJJNL/tNJGtIJ Department of Industria[ Accidents Office ,of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: 7�'rl 't Address: s` v- C�)p_,egaad Cg-,w-C� #: 5a F�_- 3�j Are you an employer? Check the appropriate box: Business Type (required): 1. F�rI am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no T ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 4- , 10. ❑ Manufacturing 10.E] no employees. [No workers' comp. insurance required]* Health Care I. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other Imy applicant that checks box #1 must also till out the section below showing their workers' compensation policy information. 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganimtion should check box #1. aur an employer that is providing workers' compensation insurance for my employees. Below is the policy information. lsurance Company Name: J--1 V C r -f C4 ( l (d 1 lil G(, 1 ! V t � Ur CC0 C �. isurer'sAddress: itylState/Zip: 'BL)S+00 I ` �y<<5 olicy # or Self -ins. Lie. # w(f' 5— 31 S — 33 (ot-i Z'3- 019 Expiration Date: 5I,W/2-01`1 .ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tie 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 Fop to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of tvestigations of the DIA for insurance coverage verification. rlo herebylcr{tify, uneer th(pains and penalties ofpwjm), that the information provided above is true and correct. II/Zt hone #: 508' 2 - L4 [ (l ei Oji JD�s-33q'- 2(_2� Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AR INFORMATION PAGE Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-386428-019 RENEWAL OF: WC5-31S-386428-018 Account Number 1-386428 1. Insured and Mailing Address ART AND SOUL TATTOO LLC 88 COPELAND DRIVE MANSFIELD, MA 02048 Liberty Mutual. INSURANCE 175 Berkeley Street Boston, MA 02116 Issuing Office 016C Issue Date 04-05-19 Sub Account 0000 RISK ID 000953803 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 05-30-2019 to 05-30-2020 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,0 00 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 189 (MA) Total Estimated Annual Premium $ 346 Premium will be billed ANNUAL Producer -013766 C & S INSURANCE AGENCY INC PO BOX 406 MANSFIELD MA 02048 WC 00 00 01 A © 1987 National Council on Compensation Insurance,lnc. WC 00 00 al Bf ) Ed. 07/01/2011 All Rights Reserved g 1 o Insured Copy WORKERS COMPENSATION AND EMPLOYERS LIABILITYLiberty Mutual. INSURANCE POLICY 10k INSURANCE AR INFORMATION PAGE 175 Berkeley Street Boston, MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-386428-018 Issuing Office 016C RENEWAL OF: WC5-31S-386428-017 issue Date 00003-18 Account Number 1-386428 Sub Account 1. Insured and Mailing Address ART AND SOUL TATTOO LLC RISK ID 000953803 88 COPELAND DRIVE MANSFIELD, MA 02048 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM -EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 05-30-2018 to 05-30-2019 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: 100, 000 each accident Bodily Injury by Accident $ Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. E ted Annual Code Classifications Number Premium Basis Total Estimated Annual Remuneration Minimum Premium $ 192 (MA) Premium will be billed ANNUAL Producer 0004.013766 C & S INSURANCE AGENCY INC PO BOX 406 MANSFIELD MA 02048 Rate per $100 stlma of Remuneration Premium Total Estimated Annual Premium $ 747 WC 00 00 01 A ©1987 National Council on I Rights coResmpensation Insurance,lnc. Ed. 07/01/2011 Insured Copy WC 00 00 01 B (CA) Page 1 of 1 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 03��g7ss1. "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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.dac HE68K Y bAVr- h rMA0 R aagi. ',Ire- eases Heartsaver® American First Aid U AED O.Heart Association® Anna Michener The above individual has successfully completed the objectives and skills evaluations in accordance with the cuf iculum of the AHA Heartsaver First Aid CPR AED Program. Optional completed modules are those NOT marked out: Child CPR AED Infant CPR Exam 02/07/17 02/2019 Issue Data Recommended Renewal Data s ' 'aauerzadda sU HIRIIµVs�+sl4s yyM Euued 1 uO'sP1�m veaH vasuaup 5le2® >zrersr LAS umeaweN 9611080801,0 nowwt$y i010114sul - # 01 "lsOl . dW'PlaysueW u011eo01 esmo0 =10 o)ui 0209-982{805) 99LZU dW 01 SZ90ZtlW sAsgePa $ utmew ua aamg aweN JOW00 6ululsil N 0101 a 0 @ Verizon ^^ 2:06 PM ®R O *or Doc wallet -card 1.pdf Quality Training: When you want It, where you want it. 1..___.____..__________________________________________________i i Bloodborne for Body Art M, Wursn 111"I"00% Via 1"("1g, 04"Ml.1d l0 crMulo+01 reit) OSHA 8!o bar r N tWs $4vltt N 29 QrR 1910.1030 _ 1 .1tl 1<1y 1t9nLtY 1 n ProTminln0s.com canpany ^1r1n 1 -1 i tw. t r it Pa45 IM1 ItH L-'. Illry �lI IIY1Mnli lip,l lh' ni 11-.11111111,111,111., Yr M:.. `i 'll 1 VVtal .p II (." � IwLOb1A9 Ib �gPNlu.)t {q. �f').9 CfflihlD.1GM li VJ.+.v J�] LNr`n S+.V.I nMll^.IYn�54^tN nl(.. a) vi ltv.lry i ANNA MICHENER I �thsca.gaet11tn4xpntipladdm�xPtllin4�nv pr 4bey/aY -�+xxn�z.ovv.�fioi+v y 1 I Date Issued: 12 Feb 2018 Renew By: 12 Feb 2019 w m:tw; ROY W. SHAW 4100 i '.. I Certificate Yl 181848958861901 ..ma.m umo..miwem„�e.m�� .wwneN,a,�.,x,ca.�m r Dear Anna, Above you will find your Bloodborne for Body Art certification card. You may also access this page ata later time by logging Into tattoo.probloodborne.com and clicking the Print Certificate button. 1V1AJiXt�JP i'iS DRIVERS LICENSE � � F e 11Y16 ��III fp} 1 1z ANN' O -.I!L "' it } `� , I: r � •e35 H LANA AVE e x � , 'MAN JEIA MA)f30A&'fiAB _I � K '� �� yaerss HAZ .asasxF �sxcr 5g01i � E i 1 % soo im5mfegwdvmnm ,�,z�a��/% t Y 1 RUN DATE: 11/12/18 Sturdy Memorial Hospital LAB *LIVE* PAGE 1 RUN TIME: 1544 SMH SPECIMEN INQUIRY RUN USER: MHC.MR PCI User: MHC.MR Lab Database: LAB.STU PATIENT:-MICHENER,ANNA NOELLE ACCT #:-29806692 : LOC: MHC U #: 079461 AGE/SEX 26/F ` DOB: 12/25/77 ROOM: REG: 03/19/04 REG DR: 'SHAVER MD,JOHN C. STATUS: REG CLI BED.: DIS: - Specimen: 0319:Z00004R Collected: 03/19/04-1000 Status: COMP Req#: 01806037 Received: 03/19/04-1557 Subm Dr: WALSH FNP,NANCYANN Ordered: HBSAB Test Result :Flag Reference Site >HEPATITIS B SURFACE AB _. 369 IU/L A. This patient has either: had an antibody response to HBV vaccination or has had Hepatitis B and recovered. This patient 'should 'be considered'. immune to Hepatitis B. An anti - HBs result equal to or.greater than 10 IU/L implies ,eimmunity. For -post vaccinationantibody testing guidelines, see MMWR 39(S-2):1-23, Feb 9, 1990. 'anti -HBs Titers Less than 10 IU/L .... Negative 10 to 100 TuIL ...:. Weak.:. Positive 100 to 1000 IU/L .... Positive Over:. 1000 IU/L .... Strong Positive -.. TEST INFORMATION: Hepatitis B Surface Ab _.Result:` greater .than orequal :,to 101U/L implied immunity. - For post -hepatitis B vaccine antibody testing guidelines, refer to MMWR 39°(S2).:1-23, Feb 91 1990. The performance characteristics. of this test were validated by ARUP Laboratories, Inc. The U.S. Food and _ ;Drug Administration (FDA) has not approved this test.': The results are not intended to be used as the sole means ' for clinical diagnosis or patient management decisions,. ARUP is authorized under Clinical Laboratory Improvement - - ,Amendments (CLIA) and by all states' to`.perform :.high-."" complexity testing. The above test•. was performed at: Associated Regional and University Pathologists, 500 Chipeta Way, SLC UT 84108 A - ARUP Associated Regional and University Pathologists, Inc. 500 Chipeta Way, Salt Lake City, Utah, 84108 ** END OF REPORT ** 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 This is to certify that., Permit Number: 14 LAWRENCE COLALUCA III IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS located at: Tattooing Body Piercing Micropigmentatio ART & SOUL TATOO 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 2/26/2020 American Red Cross CPR/AED -Adult Certificate expires: 212612020 Bloodborne Pathogens Certificate expires: 212612019 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 Michaet'HeaCey, Chairman fi�3. r ;y aid DriveMansllviddh (�'ui ; i t vial � tul.i'. P fk_5u ',50,833M,2001 19 AnnaM1(dhC;ner, OwEteI' Of' )'rt rYy >Qfi_I! "ItIo,' , <'< {s ;, r:4r') year ta" too appreyiticeship to Col OW-ing stIpUla6tions: 1. Set hours & mutual eonaauit,` (1 (t, 5_ire.l�rlr :l'lae Hepatitis B vaccination, .,r °r ,3 Lrtir r < G(nf ; c,� 'd:� i� r pp e of /co -pry et }y t, r , iQb�..��er V�0✓IJTLLl��{1'.,J6��.Ad �V,i a, 1'M'L�,�.0 @�� 3.':t'he following certifications1"G, � '4?r.:F� & tr p o a,.14 . ;SKIFI Course for Tattoo Artistry .i'.�tir"i, ./ id,., 1._ l61�. CAJ k t.,:, 1,.Ji BGJl..r,ine pa"tho etbs 4. Agreement to tattoo onty C11. supervision &, guide 5. Hours ours o f education will sstcay -1,1p ic, + C n .Please stay home rvhe:n yo1r +rirr,; 4 ,r 7. C,i_hillirty Insurance is rrtriirr'ru i;c. '1y`/l�@f�;f,�r,,yyl��prenti�cesh✓�irlp� will begin J(�rk�tl.r�i y 3 X017 , „�a be eon --I r�cd.ed when G��'t U'S.tl�. Anna �:B.1L.10.A tl"�r_e ✓. I. �v 3. r6,r�'�.:�9� t9� 11,6. �. �� oY... C '1.�.F:_ y it iu _ �43trey Sr Lr�2gW with 11prc logged hours, of reach si'-,4 _ totl1e next level of lreensr;rre: To request consideration for cA 1 followIng is required f'or [he 16 of Town Reqs): Name, ICp�r.tG� rfllt�k A F; Address/1 a11in ddres:r, 1-1), MgoC hours frorn prior apprenticeship�s in above certifications (see Lint',J), 'theAppreirticeship could fil,Tng ' fl AI CY erins are riot maintairi.ecI or , SO I If',, rr�dhir; g wuc to be ,reallz�ed of'the *appreritk-,(-,, t -i ol k .; lau ]111 o ya L (I VJ, ,actooing ou-tside of'sl-icq-}, ii -i ling, darnal)ing equipmeicit Ii-Irull/Col" S-'JHOV's With dients, any sport of'h.-u,iai.cq.n IJ cAlkA Ip --v f""Ld k like acti vil- tics wild part] ,f,-.�cl i'll, �-ndangered species incltiC'h;g UIA lk° creatures, trash talk1n1-j ala.! ":i Tt I C, 0 D y goes for both parties), etc,, A�civica, sigili below and prourfisc U,.� '�11(,,,�P,-O-J. 'Lo thIle boo� U1, I,N�� e�,OJM "S —J- f'cvur II R�Iq-171'11 S " oy I�ollll' 7 " asi YOU toc,�, IIS , on ly A - Teri ,;i, I'll.Micherter, Owner/Artist Oul !'S''otTA x Print: Town of Mansfield Town of Mansfield - Board of Health. 6 Park Row Mansfield, MA 02048 Apprentice Practitioner's OPERATOR NAME: for Offering Body Art Services Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: fI /�f Gf (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: 6wY`-� �,4-w /-4- ij,A5 1 , i t CITY: MAILING ADDRESS: CITY: l STATE: AAA- ZIP: OlNf STATE: ZIP: PHONE NUMBER OF OPERATOR: 46C $U' 3�LQ LP EMAIL OF OPERATOR I_ot talui(a- rd PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: JX 000kiGAA oiY CITY: (A QY1�p, Q � A STATE: ZIP: PHONE NUMBER OF ESTABLISHMENT: S03 i31 a D O i TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) 9 Tattooing ❑ Body Piercing Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: N et IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Please attach copies of appropriate documentation First Aid and CPR Certifications for tattoo and piercing American Red Cross Standard First Aid Certificate expires: American Red Cross CPRtAED - Adult Certificate expires: Preventing Disease Transmission and/or Bloodborne Pathogen Training Bloodborne Pathogens Certificate expires: Corse work /training on human anatomy (body piercing only) Course work / training on skin diseases, disorders and conditions for tattoo and piercing Hepatitus B vaccination status or Declination Notification Leiter Signed and motorized agreement with a permitted Body Art Practitioner 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. c.111 § 31. Practitioner permits shall be valid from the date of issuance and shall expire on the last day of the year of issuance unless revoked sooner by the Boayd. 1i Signature - —_ Date: (/ 2 i / 26 PI FEE: $75.00 a 0 A w Z/Z XOSNI/01Ine;ap_japlo;gpew/xo,ol_ddegii#/almsdde/woo Aliupx,loauuoo//:sdpy I, Lawrence Colaluca II1, will be declining the hepatitis B vaccination shots. I acknowledge its significance and the risk I am taking. Lawrence,Colal ca III 2-1 M xoqul 13auuo0 AlINIdX MOZ/5N£ w A: c. cc a �: �� w Quality Training: When you want it, where you want it. r""""'—'"""'—""—"""""""—""""""---""-- I 1 Bloodborne for Body Art This course includes the following objectives and is consistent 1 with OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 1 and body art safety 1 1 1 a ProTrainings.com company 1 -Infection Control mir Body Mists -Regulated waste 1 -How Bloodborne Pathogens arespeatl-Body Fluid Cleanup Procedures 1 1 This card certifies that the individual has successfully completed the 1 -HIV and ATOS G. Removal ; -Hepatitis B Vims and Vaccine-Handwashing education in OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 1 Procedures for Body Art Shops 1 s -&,d -Son 1 and body art safety hmn and Reporting 1 -Skin Diseases-Exposare Diseases RikIncident -Medical Issues Nth Body Art -Retlucing Risk 1. 1 LAWRENCE COLALUCA -engineering and work Practice contras -Cross Conwminalion 1 -Course is 2 contact hours 1 has completed training in Bloodborne Pathogens for Body Art 1 1 Date Issued: 26 Feb 2018 Renew By: 26 Feb 2019 1 OV W. SHAW #100 Instructor: R 1 1 1 Certificate # 151973393632314 e8e-106-7487 tatmo.pmdoodmum.com support@pmo alnings.com 1 L_________________________________________ —___ —____— —________J Dear Lawrence, Above you will find your Bloodborne for Body Art certification card. You may also access this page at a later time by logging into, tattoo. probloodborne.com and clicking the Print Certificate button. Quality Training: When you want it, where you want it. ------___--'----------------------------------------'_-----'i This Certification includes the following objectives and is ' ProFirstAid Basic consistent with national consensus 2015 ECC/1 1 � and American Heart Association® Guidelines. � a ProTrainings.com company -Adult CPR - Universal Precautions 1 -AED - Diabetic Emergencies This card certifies that the individual has successfully completed - Bleeding Control - Stroke the National Cognitive Evaluation in accordance with ProTrainings - Musculoskeletal Injuries - Burns 1 1 Curriculum and the American Heart Association® guidelines - Poisoning - Bites and Stings 1 - Shock Management - Allergic Reactions 1 1 LAWRENCE COLALUCA - Breathing Emergencies -Seizures 1 1 has completed CPR & First Aid AED inclusive Certification 1 P i j, - Heart Attack - Heat and Cold Emergencies 1 - Choking, Conscious and Unconscious 1 1 Date Issued: 26 Feb 2018 Renew By: 26 Feb 2020 � Instructor: ROY W. SHAW #100 1 Certificate # 151973393632316 888-408-7487 basic.profirstaidcom support@pmtminings,com 1 L------------------------------------------------------------ J Dear Lawrence, Above you will find your ProFirstAid Basic certification card. You may also access this page at a later time by logging into basic. prof I rstaid.com and clicking the Print Certificate button. You will also receive a permanent copy of your card in the mail 5-7 business days after the date of purchase. Below is the mailing address to which we will mail your card. If there are any problems with any part of this card or address please let us know ProTrainings Customer Solutions Mon - Fri, 9am - 8pm EST Phone: 888-406-7487 Email: support@protrainings.com LAWRENCE COLALLICA 605 ADMIRAL ST PROVIDENCE, RI 02908-1427 us �\ ! IaG VVI/IIIf VI11Y N/III f lI1 NUJNY//NJGffJ Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: d c—lSu L �4—C City/State/Zip: (1�`�S Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5_ ❑ Retail Arpart-time).* 6. F-1 Restaurant/Bar/Eating Establishment 2. 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. g. ❑ Non-profit [No workers' comp. insurance required] i, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 4. 10. F] Manufacturing no employees. [No workers' comp. insurance required]* 1 L❑ Health Care -T—� 1. F-1Weare a non-profit organization, staffed by volunteers, l 0 O with no employees. [No workers' comp. insurance req.] 1219 Other l \ny applicant that checks box #1 must also fill out rhe section below showing their workers' compensation policy information. 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganization should check box #1. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. isurance Company Name: isurer's itylState/Zip: olicy # or Self -ins. Lic. Expiration ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Pup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the fo insuralia coverage verification, do hereby ce1Ki , unde the pglns a j d/n� t es ofpety.my that tire information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact wRM1V.mass.gov/dia Phone 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. "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, *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\Scotts Uocuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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 This is to certify that: SHAWN MULLIN Permit Number: 13 IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS located at: Tattooing Body Piercing Micropigmentatio ART & SOUL TATTOO 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 11/22/2020 American Red Cross CPR/AED -Adult Certificate expires: 1112212020 Bloodborne Pathogens Certificate expires: 1112212020 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 Michae(9HeaCey, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Practitioner's Application for Offering Body Art Services OPERATOR NAME: Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. , DATE OF BIRTH: (� 1(' -7q (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: �R4 :506'1 -A CITY: 6i"Cr(�V-112 STATE: III& ZIP: 61121 10t MAILING ADDRESS: 1 CITY: �'j t"IG c `JG✓) SA CZ) (6c I'(„�OVlSTATE: t r l I I ZIP: OJ 3C) PHONE NUMBER OF OPERATOR: % y L]14 EMAIL OF OPERATOR: `t /1 PLACE OF EMPLOYMENT AS A PRACTITIONER: A r av�,A 'j o o C Ct -�i C1 D ADDRESS: (qi CGpC ICt✓}�. Oi CITY: A/\,g' :i ('gA STATE; ZIP: PHONE NUMBER OF ESTABLISHMENT: TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) tK Tattooing K Body PiercingMicropigmentation PROJECTED DATE FOR BEGINNINGGOR RENEWAL: Ill) ft , IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Please atta6h copies of appropriate documentation First Aid and CPR Certifications for tattoo and piercing American Red Cross Standard First Aid Certificate expires: American Red Cross CPR/AED - Adult Certificate expires: Preventing Disease Transmission and/or Bloodborne Pathogen Training Bloodborne Pathogens Certificate expires: Course work /training on human anatomy (body piercing only) Course work / training on skin diseases, disorders and conditions for tattoo and piercing Hepatitus B vaccination status or Declination Notification Letter Evidence satisfactory to the Board of Health of at least two (2) years experience prior experience or a completed approved apprenticeship program (n1a for renewals) 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. Practitioner permits shall be valid from the date of issuance and shall expire on the last day of the year of issuance unless revoked sooner by the Board. Signature: w(j<L{t Dater l FEE: $100.00 ,,4i VJ IiJ NJJNL/44iJL4[J Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 6 4 � Q2 klL�� }� CC LK-2 Address: C UC LVVI (2K City/State/Zip:VAQ,�Lttc rt fj�Y vat, Y Phone#: zC si 1i— Vire you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 1. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] I. ❑ We are a corporation and its officers have exercised their right of exemption per c. 153, § 1(4), and we have no employees. [No workers' comp. insurance required]' I. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. 0 Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12. Odter TCect) \ny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. `lf the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganiution should check box #I. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. isurance Company Nan isurer's Address:_ ityl,State/Zip: olicy # or Self -ins. Lic. Expiration ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposifion of criminal penalties of a ne 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 F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify, under the pains and penalties of perjml, that the information provided above is true and correct, honey 7Z�j q1/g-9j5q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dm 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 **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\s1eite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc To whom it may concern, I refuse to recieve the Hepatitus vaccination at this time. Shawn Mullin N .4 _ DRE Ry , z U LU w A. w z UO X0 <wz0 Q U d � It N t Z QW Ix ? U LL N W, U �3 0�0 9100 W � Wz } �Wo NO� UWU N O 2 �C2Q 0 pw� Z N 0 N o(5 T00m 610 J z C U �w m t �' r