HomeMy WebLinkAboutMaster's Method Tattoo, Inc. - 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
This is to Certify that:
Permit Number: 3
MASTER'S METHOD TATTOO, INC.
116 NORTH MAIN STREET
MANSFIELD MA 02048
IS HEREBY GRANTED A PERMIT
FOR A BODYART 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 of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
r ? E
ESTABLISHMENT NAME:
ADDRESS: ��(.�h _..
CITY: 1 STATE: __ ZIP: 03aTa
PHONE NABER OF OPERATION: 11Li �icl-- a. otr..t
NAME OF OWNER�n�
ADDRESS:t,rn} _ 1�1__ _ _.. ... .._—
CITY: —.. .y} iA1(7K(j STATE: � ZIP: C)�'�—(sjD
PHONE NUMBER OF OWNER:
EMAIL OF OWNER:
NAME OF CORPORATION / ASSOCIATION / PARTNERS l�•i ���..�rli'sj,'�__
NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR
MORE IN THE CORPORATION / ASSOCIATION / PARTNERSHIP:
PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED
WITHOUT PROPER CONSENT
WC, Gh�f� ctl� (mss "-3e-c C'ce.p.�r fir= 1� r �
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MAILING ADDRESS FOR APPROVAL NOTIFICATION AND KtNtwAL:
TnTAI R17F OF OPERATION IS: 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,1g,-,
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 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.
11C) .— ..--
Signature of establish" ment owner Date Print name of establishment owner
FEE'. $200.00
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: �Q � � d <D() I ViC
Site Address: \\(, ��N(3V�77P4�� \" O_Ln
City, State, ZIP: V� �i M p,
Type of Body Art Facility: 7ai60 � �� ��2rCc In
Contact Person: ACzrc�>n
Date of Ph
Signature
Page 1 of 7
Telephone: -1"-1L4 _1 [9 -
Body Art Facility Infection Prevention and Control Plan
A. Decontamination and Disinfection: Describe the procedures for decontaminating and disinfecting of
workstation and surfaces
Wnrkct; inncijrfarac/rnijntertons-
2. Workstation chairs/stools:
3. Trays:
4. Armrests:
5. Headrests:
;��Cwp.
6. Procedure area:
< XDE
7. Tables:
Gamy -
Page 2 of 7
Body Art Facility Infection'Prevention and Control Plan
8. Tattoo machine and Clip Cord:
9. Reusable instruments, calipers, needle tubes, etc. portable light fixtures or other:
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
2. Calipers:
3. Other instruments:
M
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
Page 3 of 7
Body Art Facility Infection'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
1
2.
3. Branding:
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.
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.
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.
1. Needles and needle bars:
2. Razors:
3. Others harps or single -use marking pens used on open skin:
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.
I. 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.
J. Disinfection Products: List the disinfectant products used at the body art facility.
X191 CACa I GE�rc`0'iG�f a� 8[)l 0%0f) oor O1 %fit Jtr�
Page 6 of 7
Body Art Facility Infection Prevention 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: _ ?b 0)� \k �0C
Temperature: 3no G
Psi:
L. Personal Protective Equipment: List the personal protective equipment used during a body art
procedure for the practitioner and the client.
M. Handwashing Sink: List the locations of the hand wash sinks and describe the items supplied at
onnh sink
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. J
'_PkCf_1P `c'2 CSA C
O. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when
there is an accidental spill of sharps.
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.
Page 6 of 7
Body Art Facility Infection`Prevention 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.
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 pments.
S. Service Animals: Describe the facility's policy regarding service animal presence in procedure,
decontamination, and sterilization areas.
Wa j ��MCL`l 1 —
Maintain a copy of this completed document in your files. Submit one copy to the Mansfield Board of
Health.
1 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 and information contained in this document. To the best of my knowledge and
belief, the st@tements made herein are correct and true.
Signature:
For Body Art Practitioners practicing at the establishment: I hereby certify that 1 have been trained
with the procedures and information contained in this document. To the best of my
knowledge and belief, the statements made herein are correct and true.
Signature:
Date: _ 12-
Page
2
Page 7 of 7
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.
1 " Y tj's mjm� Q11M
Si�ure of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*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 Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
October 25, 2018
Body Art Establishment Owners:
Town of Mansfield
6 Park Raw, Mansfield, Massatbusells 02048
Health Department
Amy Donovan-Palrner, MPH, RS, Health Agent
All Body Art Establishment, Practitioner and Apprenticeship Permits will expire on December 31, 2018.
To renew your permits, please submit the attached documents and payment to the Health Department. Please
note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete
filings will be returned and no permit will be issued.
Body Art Establishment Permit:
1. Application for Offering Body Art Services
2. Required forms listed on the Application
3. Body Art Facility Infection Prevention and Control Plan signed by all Practitioners practicing at the
establishment.
4. Tax Certification Form
5. Worker's Compensation Insurance Affidavit: General Business is required. (Read the third paragraph
on the "Information and Instructions" sheet.)
Body Art Practitioner Permit:
1. Practitioner's Application for Offering Body Art Services
2. Copies of necessary documentation listed on Application
Body Art Apprentice Practitioner Permit:
1. Apprentice Practitioner's Application for Offering Body Art Services
2. Copies of necessary documentation listed on Application
New permit fees, adopted by the Board of Health in September 2018, will apply to these renewals.
Permit
Fee
Body Art Establishment
$200
Body Art Practitioner
$100
Body Art Apprentice Practitioner
$75
Please contact the Health Department if I can be of any further assistance.
Sincerely,
�. tnnu, r0, )6r0 el 1 JVva.l\
Amy Donovan -Palmer, MPH, RS
Health Agent
Pbone (508)261-7366 Fax (508)261-7425 Emailadpalmer@maneldma.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: JVt o �r-1'f 1 V561 151-
City/State/Zip:
Phone4: a(
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑ I 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
7, ❑ 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.pAe are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(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,
^�
with no employees. [No workers' comp. insurance req.]
12.0 Othef 1r:�-� $ 1 o fc q
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. U
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box H 1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration
Attach a copy of the workers' compensation policy declaration page (showing 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 imprisomnent, 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains mrd penalties ofperjury that the 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 Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.nrass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license nwnber on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fenn Revised 5-26-05
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: 9
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing Body Piercing Micropigmentatio
located at:
MASTER'S METHOD TATTOO, INC.
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPR/AED - Adult Certificate expires: 4/6/2020
Bloodborne Pathogens Certificate expires: 9/712019
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
Michaei(HeaCey, Chairman
Town of Mansfield
Town of Mansjield - Board of flealth 6 Park Row
Mansfield, MA 02048
Practitioner's Application for Offering I3atly Art Services
OPERATOR NAME: % \cxt7(( t;r r-),Ctr
Please attach recent identification photograph here
in size. Clear photocopies are acceptable.
DATE OF BIRTH: _
RESIDENCE ADDRESS: in c.7c
head and shoulders. front view.) approximately 2x3 inches
(A practitioner shall be a minimum of 18 years of age.)
CITY: �fAh STATE:{ ZIP:
MAILING ADDRESS:l
CITY:
STATE: ZIP:
PHONE NUMBER OF OPERATOR: 1!k53 `(p�y� ----
EMAIL
_EMAIL OF OPERATOR: M VCtfl r. Vm m•{- �' C]YtiYJa` —GDt�
PLACE OF EMPLOYMENT AS A PRACTITIONER:
ADDRESS:
CITY:
TE: MIA__ ZIP:
PHONE NUMBER OF ESTABLISHMENT:
TYPE
E-O/F p. RACTITIONER PERMIT APPLYING FOR: (Check all that apply)
K,Tattooing Fr Body Piercing ❑ Micropigmentation
PROJECTED DATE FOR BEGINNING OR RENEWAL:
IFA TIME LIMITED EVENT, NAME AND ADDRESS OF EVEN
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 CPRAAED - 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 of a
completed approved apprenticeship program (n/a forrenewats)
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 revoke/dsosooner by the Board.Av
7
Signature: fix" Date: ax n)
FEE: $100.00
Aaron Rampello
has successfully completed this online course
BBP for Tattoo Artists
Online
September 7, 2018
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To Whom it May Concern,
I ' o Aaron Rampello herby decline the Hepatitis B Vaccination.
Aaron Rampello
Master's Method Tattoo
/tLD'LLRIP43si1
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.,
JAIME CARLETON
Permit Number: 11
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing Body Piercing Micropigmentatio
located at:
MASTER'S METHOD TATTOO, INC.
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPRIAED - Adult Certificate expires: 419/2019
Bloodborne Pathogens Certificate expires: 12/412019
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
AlchaeCHeaCey, Chairman
Town ref Mansfield - Board of Health
OPERATOR NAME:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH: (A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS:
CITY: _ Np (^-r l 1 "�/�'}�{,-,� iY�.Cv_. STATE: �_� ZIP:.
MAILING ADDRESS:y-ter * 1��...____ _—
CITY:
STATE: ZIP:
PHONE NUMBER OF OPERATOR:
EMAIL OF OPERATOR: Vl rv,nvr r+n v-4,%4 ei r1l rc)w�
PLACE OF EMPLOYMENT AS A
ADDRESS: _%�_111 _ cV V t 7 r � t- v " r Iy_
CITY: J*XSfild STATE: M A ZIP: CS 0WK_ _._
PHONE NUMBER OF ESTABLISHMENT:
TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply)
L9
Tattooing " Body Piercing ❑ Micropigmentation
PROJECTED DATE FOR BEGINNING OR RENEWAL: __ -�t . _�_i -
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 CPR/AED - Adult Certificate expires:
Preventing Disease Transmission and/or Bloodbome 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 (n/a fortenewals)
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. 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 sooner by the Board.
Signature: Date: —
FEE: $100.00 _ I
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Certificate of Completion
Jaime Carleton
has successfully completed requirements for
Adult and Pediatric First Aid/CPR/AED - Valid 2 Years
conducted by
American Red Cross
Date Completed: Sun Apr 09 2017
Instructors: Jay Atkins
O ..
Certificate ID: OZRGYS
To verify, scan code or visit: https-l/www,redcross.org/ontdamandmro.store/Sites-RedCross-Ske/defaulVCertificates-
ViewAndPrint?certnumber--OZRGYS&selectedCerts=ld-OZRGYS
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
Master's Method Tattoo, Inc.
Program Administration Jaime Carleton, is responsible for the implementation of the Exposure Control
Plan (ECP). Jaime Carleton, will maintain, review, and update the ECP at least annually, and whenever
necessary to include new or modified tasks and procedures.
Those employees/apprentices who are determined to have occupational exposure to blood or other
potentially infectious materials (OPIM) must comply with this ECP.
Master's Method Tattoo, Inc., will maintain and provide all necessary personal protective equipment
(PPE), engineering controls (e.g., sharps containers) as required by the Medical Waste Management Act
and OSHA standard. Master's Method Tattoo, Inc., will ensure that adequate supplies of the
aforementioned equipment are available at all times.
Jaime Carleton, will be responsible for training, documentation of training, and making the written ECP
available to employees.
Exposure Control Plan Employees covered by the bloodborne pathogens standard receive an
explanation of this ECP during their initial training session. It will also be reviewed in their annual
refresher training. If requested, we will provide an employee with a copy of the ECP free of charge and
within 15 days of the request.
Jaime Carleton, is responsible for reviewing and updating the ECP annually or more frequently if
necessary to reflect any new or modified tasks and procedures which affect occupational exposure and
to reflect new or revised employee positions with occupational exposure.
In accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, the following
Exposure Control Plan has been developed.
1. EXPOSURE DETERMINATION OSHA requires employers to perform an exposure determination
concerning which employees may incur occupational exposure to blood or other potentially infectious
materials. The exposure determination is made without regard to the use of personal protective
equipment (i.e., employees are considered to be exposed even if they wear PPE).
2. IMPLEMENTATION SCHEDULE AND METHODOLOGY OSHA also requires that this plan include a
schedule and method of implementation for the various requirements of the standard. The following
complies with this requirement.
Compliance Methods Universal precautions will be practiced in this facility in order to prevent contact
with blood or other potentially infectious materials. All blood or other potentially infectious material
will be considered infectious regardless of the perceived status of the individual.
Work practice controls will be used to eliminate or minimize exposure to employees at this facility.
Where occupational exposure remains after institution of these controls, personal protective equipment
shall also be used. At this facility the following controls shall be used:
Gloves are used during all tattoo and body piercing procedures.
A new pair of gloves are put on during each step of tattoo process:
(1.) The cleansing of the skin for tattoo procedures
(2.) Application of the stencil (where the stencil is promptly thrown away)
(3.) After the tattoo procedure is complete the artist discards current gloves and puts on new gloves, and
thoroughly wipes down the tattoo
(4.) Gloves shall be used in the cleaning process. All work surfaces and equipment including the tattoo
chair and client chair, arm rest or anything that was possibly contaminated during the tattoo procedure
shall be cleaned and sanitized with an antimicrobial spray.
(5.) Gloves are worn throughout the entire piercing procedure and new gloves are put on for the
breakdown, cleaning and sanitizing of the piercing room.
Gloves are used when removing waste and garbage and when cleaning and sanitizing the shop or any
surface that could have possibly been contaminated.
Subsequently, the artist will properly dispose of gloves and wash his/her hands with a germicidal soap
containing Chloroxylenol after cleaning work surfaces and equipment.
All items of equipment which may be touched during the tattoo process such as clip -cords, machine
heads, spray bottles, etc., shall be covered with disposable impervious barrier covering and removed
after the tattoo procedure is complete and the client has left the procedure room.
Handwashing facilities are available to employees who may incur exposure to blood or other potentially
infectious materials. In this facility handwashing facilities are located in each artist station.
Before and after each procedure each artist must wash their hands and lower arms with warm water
and soap containing Chloroxylenol.
Where the skin has been broken and body fluids from a client has entered the practitioner's skin the
protocol we use is to scrub the area immediately with Microsan and a soap containing Chloroxylenol and
seeking medical attention.
In a more minor exposure where the practitioner skin has not been breached and blood product has
come in contact with the skin we would scrub the area immediately with Microsan and a soap
containing Chloroxylenol. All exposure incidents are documented.
Contaminated sharps shall not be bent, sheared or purposely broken. Contaminated sharps must be
placed immediately, or as soon as possible, after use into appropriate sharps containers. Sharps
containers must be puncture resistant, labeled with biohazard label, and leakproof.
Sharps containers are located in each artists station. When the sharps containers are full they are picked
up by AdvoWaste Medical Services, LLC Boston, Ma Phone: (855-678-1098)
INCIDENT/COMPLAINT REPORT
EMPLOYEE: Return this COMPLETED FORM to your SUPERVISOR as soon as possible.
Name of Person Involved:
Address: City:
Phone Number: Age: DOB: Sex: M _
SS#: Date of Incident: Time: am/pm
Exact Location of Incident:
Check Type of Accident: Check:
Artist
❑ Safety Client
❑ Device Failure
❑ Policy/Procedural Violations
❑ Needlestick
❑ Exposure to Hazardous Substance
0
EMPLOYEE: Involved yes no
Were they doing their regular job duties: , yes _ no Observed by employee E:1 yes
Hire Date: Situation observed only by employee yes p
Employee Classification:
Protective Equipment being used: yes no
If not used, Why:
Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events, personnel
involved, body part injured, reason incident occurred) (If medication error include brand name,
manufacturer, dosage) (Use additional form if necessary)
Taken by Staff Members:
Witness Name:
Address:
Witness Name:
Address:
MEDICAL FOLLOW-UP:
Treatment Refused: _
Treating Physician:
Address:
First Day Off Work:
Duties Restricted: _ yes no Explain:
INCIDENT/COMPLAINT REPORT
Phone Number:
Phone Number:
Was Medical Attention Sought: yes no
_ yes no First Treatment Date:
Phone Number:
Return to Work Date:
Incident Reported By:
Supervisor Notified: yes no
Name of Supervisor:
Signature and Title of Person Preparing F
Date:
Time:
Supervisor Comments:
Supervisor
Date:
Corrective Action Taken/Follow-Up: (Things that have been or will be taken to prevent recurrence)
Director comments:
Director Signature: Date: _
Nursing Administrator Signature: Date: _
Administrator Signature: Date: _
Signature of Person making Complaint: Date: _
Worker Compensation first Report Sent: _ yes _ no Date: OSHA 300 Log #
I understand the potential risks related to the exposure to the incident that occurred and agree to
receive an examination and/or treatment for the exposure, as recommended by my physician. This
includes serological testing for Hepatitis B and the HIV virus as indicated.
I understand the potential risks related to the exposure incidents that occurred and DO NOT agree
to have an examination or treatment for the exposure.
Employee Signature:
Supervisor Signature:
Date:
Date:
I understand the information above will be used by my employer to help determine liability for injury. I
acknowledge that the above statements are true and accurate representation of the requested
information.
Employee Signature: Date:
Job Title:
MASTER'S METHOD T4I"100
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodtattoo.com
Aseptic Tattoo Procedure
1.The area of the body to be tattooed, and all parts of the body which are visible, shall be examined for
signs of intravenous drug use, open sores, lesions, oozing wounds, and skin diseases. If such are found,
or suspected, the person shall not be tattooed. In addition, we will also look for moles or anything that
could possibly become a problem in the future.
2. Before working on each client, each tattoo artist shall thoroughly wash and scrub hands and lower
arms with hot running water, using germicidal soap containing Chloroxylenol or equivalent from a
dispenser.
3. All materials necessary for the tattooing process shall be set up on a single use disposable cloth (i.e.
polycloth). The polycloth shall be placed absorbent side up to prevent leakage.
4. All items of equipment which may be touched during the tattoo process such as clip -cords, machine
heads, spray bottles, etc., shall be covered with disposable impervious barrier covering.
5. Lubricants will be used out of single -use tubes or shall be removed from a tub with a single -use tool
(i.e. tongue depressor) and placed on a polycloth and tool will be disposed of.
6. The skin shall be prepared first by thoroughly washing with soap containing Chloroxylenol, preferably
Microsan.
7. Any shaving shall be done with a single -use disposable razor and then promptly disposed of.
Additional soap may be used to facilitate shaving without cutting the skin.
8. The skin shall be wiped with 99% isopropyl alcohol to remove any oils or dead skin cells.
9. Stencil transfer medium shall be applied (if applicable) using a new pair of gloves or lint -free paper
towels or gauze and the prepared clean single use stencil shall be applied to the skin and promptly
discarded.
10. After applying the stencil, the tattoo artist shall remove and discard gloves and again wash and scrub
his/her hands and lower arms with soap and water and dry hands using paper towels.
11. Prior to commencing application of the tattoo, the tattoo artist shall then put on examination grade
gloves, which shall be used for a single tattooing procedure only.
12. All single -use needles will be opened with client present before the start of the procedure.
13. If there is a need to rinse the tube and needle between colors, this shall be done with distilled water
in single -use disposable containers. Water shall be poured into a single use cup from a closed container.
14. As the tattoo operation progresses, any excess dye or pigment applied to the skin shall be removed
with lint -free material and antimicrobial soap (i.e. green soap or equivalent).
15. After the tattoo procedure is complete the artist will discard current gloves and put on new gloves,
thoroughly wipe down the tattoo using appropriate tattoo cleanser (i.e. green soap or industry specific
washes designed for cleaning) and allow tattoo to dry. After drying, a lubricant shall be applied.
16. The Client will be asked to leave the procedure room.
17. Needles shall be immediately deposited into a puncture -resistant infectious waste sharps container.
Needles shall not be reused. All used needles and any contaminated material shall be handled with
gloves and discarded into approved and appropriate biohazard containers.
18. The remaining unused dye or pigment shall be discarded into approved and appropriate biohazard
containers.
19. Gloves shall be removed and discarded into approved and appropriate biohazard containers.
20. All work surfaces and non -autoclaved equipment including the tattoo chair and client chair, arm rest
or anything that was possibly contaminated during the tattoo procedure shall be cleaned and sanitized
with an antimicrobial spray. Gloves shall be used in the cleaning process. Subsequently, the artist will
properly dispose of gloves and wash his/her hands with a germicidal soap after cleaning work surfaces
and equipment.
21. After tattooing, the tattoo artist shall advise the client both verbally and in writing on the after care
of the tattoo and send the client home with the typed aftercare sheet.
MA5TER'S METHOD TA',""TOO
Master's Method Pierce & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodpierce.com
Aseptic Piercing Procedure
1.The area of the body to be pierced, and all parts of the body which are visible, shall be examined for
signs of intravenous drug use, open sores, lesions, oozing wounds, and skin diseases. If such are found,
or suspected, the person shall not be pierced. In addition, we will also look for moles or anything that
could possibly become a problem in the future.
2. Before working on each client, each pierce artist shall thoroughly wash and scrub hands and lower
arms with hot running water, using germicidal soap containing Chloroxylenol or equivalent from a
dispenser.
3. All materials necessary for the piercing process shall be set up on a single use disposable cloth (i.e.
polycloth). The polycloth shall be placed absorbent side up to prevent leakage.
4. Lubricants will be used out of single -use tubes or shall be removed from a tub with a single -use tool
(i.e. tongue depressor) and placed on a polycloth and tool will be disposed of.
5. The skin shall be prepared first by thoroughly washing with soap containing Chloroxylenol, preferably
Microsan.
6. Prior to commencing application of the pierce, the pierce artist shall then put on examination grade
gloves, which shall be used for a single piercing procedure only.
7. All single -use needles will be opened with client present before the start of the procedure.
8. After the pierce procedure is complete the artist will discard current gloves and put on new glovesl
9. The Client will be asked to leave the procedure room.
10. Needles shall be immediately deposited into a puncture -resistant infectious waste sharps container.
Needles shall not be reused. All used needles and any contaminated material shall be handled with
gloves and discarded into approved and appropriate biohazard containers.
11. All reusable tools will be put in the ultrasonic machine to be cleaned.
12. Gloves shall be removed and discarded into approved and appropriate biohazard containers.
13. All work surfaces and non -autoclaved equipment including the pierce chair and client chair, or
anything that was possibly contaminated during the pierce procedure shall be cleaned and sanitized
with an antimicrobial spray. Gloves shall be used in the cleaning process. Subsequently, the artist will
properly dispose of gloves and wash his/her hands with a germicidal soap after cleaning work surfaces
and equipment.
14. After piercing, the pierce artist shall advise the client both verbally and in writing on the after care of
the pierce and send the client home with the typed aftercare sheet.
MASTER'S METHOD TATTOO
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
Body Piercing Aftercare
1. Before cleaning, wash hands thoroughly with soap and warm water.
2. Saturate the entire piercing, including jewelry and both piercing sites with
sterile saline solution We recommend using Simply Saline (found in any drug
store in the nasal section) and let sit for 1 to 2 minutes (doing this will help
loosen any stubborn crust or blood on or around the area).
3. Saturate a cotton swab with the saline solution and swab the area (in a
spinning motion) to remove any blood product that may be on the piercing
sites or jewelry. Be sure to use a new cotton swab for each piercing site and a
new one for the jewelry.
4. Inspect piercing hourly to assess whether it needs to be cleaned. The
piercing should be cleaned as needed but no less than 4 times a day and no
more than 6 times daily, until your piercing is fully healed.
Do's and Don'ts
➢ Do not touch your new piercing unless you have washed your hands
thoroughly using soap and warm water.
➢ Do not try to remove blood product with bare hands, always use a lint
free paper towel.
➢ Do not try to remove the jewelry yourself or, if the jewelry falls out and
the piercing is not fully healed do not try to put it back in yourself.
Please call us and come to the shop and we will do it for you.
➢ Do not use Hydrogen Peroxide, Rubbing Alcohol or any other cleaning
product other than sterile saline solution.
➢ Redness and (pink or clear) oozing is normal but if the discharge
becomes yellow or green, you most likely have an infection and you
should call the shop so we can inspect and clean it or if needed seek
medical attention.
MASTER'S METHOD TATTOO
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodtattoo.com
Tattoo Aftercare
1. First, wash hands thoroughly with soap and warm water, then wash your
new tattoo with a small amount of anti -bacterial soap (preferably something
containing Green Soap) 4 to 5 times daily.
Always use COOL water, NEVER hot.
2. Rinse your tattoo thoroughly removing all soap.
3. Pat dry (do NOT rub) with a clean lint free paper towel.
4. Let air-dry for about 5 minutes.
5. When your tattoo is dry apply a very thin layer of recommended aftercare
product. Rub the ointment in for a full minute to allow your skin to absorb it
(it should be just slightly tacky).
6. Scabs may form as your new tattoo heals (do NOT pick the scabs), let them
fall off naturally.
Do's and Dont's
Tattoo exposed to the air is best when healing. Avoid exposing your tattoo to
chlorine (pools, hot tubs, saunas, and steam baths), salt water, or sunlight for
at least 7 to 10 days. These three things are the worst enemies of a new tattoo,
greatly diminishing the final product. Don't be alarmed if your tattoo becomes
itchy, dry or peeling, this is normal during the healing process. Resist the urge
to scratch as this will loosen scabbing. Instead wash with cool water or pat the
tattoo with the palm of your hand. We take great care not to cross -
contaminate in our environment. Follow our lead when returning to your
environment by not sharing any of your aftercare products with others.
MASTER'S METHOD TATTOO
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodtattoo.com
Policies & Agreements Disclosure Statement
By signing this document, I agree to the terms and conditions of Master's
Method Tattoo and have full understanding of this studio's policies.
The policies are as follows: .
-All deposits paid in exchange for a scheduled appointment are non-
refundable. -Any and all services received by any body art practitioner are
-Any and all extensive artwork exceeding one hour in preparation for a custom
tattoo is subject to an artwork fee to be agreed upon by the artist and client.
-Any disruptive behavior that may jeopardize the tattoo or piercing process
will not be tolerated and you will be asked to leave.
-Due to limited space in the studio, we respectfully ask that you be
accompanied by one person for moral support on the day of your scheduled
procedure.
-You may change your appointment two times after the initial scheduling,
after which point the deposit is forfeited.
-Appointments that are rescheduled must be done with at least 72 hour notice
providing you speak with an employee and confirm a new date.
-No cameras or camera phones may be operated in Master's Method Tattoo,
and under no circumstance may pictures be taken by customers during any
procedure.
-We reserve the right to refuse service to any person who does not comply our
policies.
I have read and understand the above information. By signing this
document, I agree to comply with the policies Master's Method Tattoo
has put into place for the safety of both client and body art practitioner.
Signature Date
MASTER'S METHOD TATTOO
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodtattoo.com
Body Piercing Disclosure Statement
As with any invasive procedure, body piercing may involve possible health
risks. These may include: Pain, bleeding, swelling, infection, scarring of the
area and nerve damage. Unsterile equipment and needles can spread
infectious diseases; it is extremely important to be sure all equipment is clean
and sanitary before use. You may not be allowed to donate blood either
temporarily or permanently.
The Body Art Practitioner Should: Ask the client about any allergies or
health issues. Properly and thoroughly cleanse the area before the procedure.
Use sterilized equipment. Use sterile techniques. Provide information on the
aftercare of the area receiving the body piercing.
Health History and Informed Consent:
The following conditions may increase health risks associated with receiving
body piercings: Diabetes Hemophilia (bleeding) Skin diseases, lesions, skin
sensitivities to soaps, disinfectants, etc. History of allergies or adverse
reactions to pigments, dyes or other sensitivities. Use of medications such as
anticoagulants (such as Coumadin) which thins the blood and/or interferes
with blood clotting. Hepatitis or HIV medication
Client Signature Date
I have received the above information. I do not have a condition that prevents
me from receiving body art. I consent to the performance of the body art
procedure and I have been given verbal and written aftercare instructions as
required by these regulations
Parent or guardian for minors (under the age of 18)
Signature Relationship
MASTER'S METHOD TATTOO
Master's Method Tattoo & Body Piercing
116 North Main Street
Mansfield, MA 02048
774-719-2821
www.mastersmethodtattoo.com
Tattoo Disclosure Statement
As with any invasive procedure, tattooing may involve possible health risks. These may
include: Pain, bleeding, swelling, infection, scarring of the area and nerve damage.
Unsterile equipment and needles can spread infectious diseases; it is extremely important
to be sure all equipment is clean and sanitary before use.
Tattoos and permanent makeup are not easily removed and in some cases, may cause
permanent discoloration; think carefully before getting a tattoo. There is also possibility of
an allergic reaction.
The inks of dyes for tattoos are color additives. Currently the FDA has approved no color
additives for tattoos, including permanent makeup.
You may not be allowed to donate blood either temporarily or permanently.
The Body Art Practitioner Should:
-Ask the client about any allergies or health issues.
-Properly and thoroughly cleanse the area before the procedure.
-Use sterilized equipment.
-Use sterile techniques.
-Provide information on the aftercare of the area receiving the tattoo.
Health History and Informed Consent
The following conditions may increase health risks associated with receiving tattoos:
-Diabetes
-Hemophilia (Bleeding)
-Skin Diseases, lesions, skin sensitivities to soap, disinfectants, etc.
-History of allergies or adverse reactions to pigments, dyes or other sensitivities.
-Use of medications such as anticoagulants (such as Coumadin) which things the blood
and/or interferes with blood clotting.
-Hepatitis or HIV medication.
I have received the above information. I do not have a condition that prevents me
from receiving body art. I consent to the performance of the body art procedure and I
have been given verbal and written aftercare instructions as required by these
regulations.
Signature
Parent or guardian for minors (under the age of 18)
Date
Signature Relationship
LEASE
This Lease Agreement (this "Lease"), dated as of May 5, 2016, is entered into by and between
PNE Realty LLC, ("Landlord"), and Aaron Thomas Rampello ("Tenant").
RECITALS
A. Landlord desires to lease to Tenant, and Tenant desires to lease from Landlord,
the Premises. The location of the Premises is depicted on Exhibit A, attached.
NOW, THEREFORE, in consideration of the premises and for other good and valuable
consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereby
agree as follows:
1. Premises. Landlord hereby leases to Tenant, and Tenant hereby leases from
Landlord one (1) storefront with three (3) working rooms and one (1) half bath (the "Premises"),
located in the building commonly known as 116 North Main Street, Mansfield, MA 02048 (the
`Building").
2. Term. The term of this Lease (the "Term") will commence on May 5, 2016 (the
"Commencement Date") and continue for a period of three years from the Rent
Commencement Date, as defined below, ending on June 30, 2019 (the "Expiration Date").
3. Rent. Commencing on July 1, 2016 (the "Rent Commencement Date") and
throughout the Term, Tenant shall pay monthly to Landlord, on or before the first (1st) day of
each month, rent ("Base Rent") in the following amount:
Period Annual Rent
Monthly Rental
Installments
Months 1-36 $16200.00
$1,350.00
Notwithstanding the foregoing, Tenant shall pay the first and last month's Base Rent upon its
execution of this Lease.
4. Use. The Premises shall be used for the sole purpose of a tattoo shop.
5. Utilities. Prior to the Commencement Date, Landlord shall, at its own expense,
insure that the Premises are served by all utilities necessary for Tenant to use the Premises as
provided above. From and after the Commencement Date, Tenant shall purchase and promptly
pay for all utilities and other services (including, but not limited to, telephone, gas, and
electricity) furnished to and or used in or at the Premises for any purpose. Landlord shall pay for
water and sewer. Should Landlord experience an average increase of over 10% in its water
bills during the Term of Tenant's occupancy, then upon any further renewals or extensions
of the Lease, Landlord shall have the right to charge Tenant for the increase.
6. Condition of Premises; Al erations• Additions Improvements. Tenant
acknowledges and agrees that Tenant accept the Premises in an "AS IS" condition, with no
obligation on the part of Landlord to improve, cause to be improved or pay Tenant to improve
the Premises, or any part thereof except as provided in Section 5 above. Tenant shall not be
1768337
permitted to make any improvements or alterations to the Premises during the Tenn without
Landlord's prior written consent. Any alterations performed by Tenant shall be in a quality at
least equal to the present construction. Tenant shall not permit any mechanic's liens, or similar
liens, to remain upon the Premises for labor and material furnished to Tenant or claimed to have
been furnished to Tenant in connection with work of any character performed or claimed to have
been performed at the direction of Tenant and shall cause any such lien to be released of record
forthwith without cost to Landlord. Upon the expiration of the Lease, Landlord shall have the
right to require Tenant to remove any alterations or improvements installed by Tenant and
restore the Premises to its original condition. Notwithstanding anything contained herein, Tenant
shall not make any structural alterations or additions to the Premises.
7. Maintenance.
A. Tenant's Obligations: Tenant shall keep and maintain the Premises in good
order and repair, damage by fire and other casualty only excepted and replace plate glass and
other glass therein, acknowledging that the Premises are now in good order and the glass whole.
Tenant shall not permit the Premises to be overloaded, damaged, stripped, or defaced, nor suffer
any waste. Tenant shall also be responsible, at its sole cost and expense up $250.00 per
occurrence, to maintain and make repairs as necessary to the heating and air conditioning,
("HVAC"), plumbing and electrical systems serving the Premises. Tenant shall not be
responsible for costs associated with the repair and maintenance of the HVAC system from July
1, 2016 through September 30, 2016, unless such costs arise as a result of Tenant's negligence in
the Premises. Tenant shall be responsible for snow removal on the sidewalk in front of Tenant's
storefront. Trash removal and recycling pick up is Wednesday mornings each week. Tenant
may add its garbage (as long as it is in bags) to the owner's barrels on the curbside Tuesday night
after 7:OOpm. Recycling items may be placed in the yellow bins.
B. Landlord's Obligations: Landlord agrees to maintain the structure of the
Building of which the Premises are a part in the same condition as it is at the commencement of
the Term or as it may be put in during the term of the Lease, reasonable wear and tear, damage
by fire and other casualty excepted, unless such maintenance is required because of the Tenant or
those for whose conduct the Tenant is legally responsible. Landlord shall be responsible, at its
sole cost and expense for repairs to the heating and air conditioning, ("HVAC"), plumbing and
electrical systems serving the Premises which exceed $250.00 per occurrence. In the event that
the heating system has reached its useful life and can no longer function properly by making
repairs, Landlord shall, at its cost, replace the system.
8. Signage. Tenant shall obtain Landlord's written consent before erecting any sign
on the Premises or Building. Upon the expiration of the Lease, Tenant will remove any signs
installed by Tenant and repair any damaged caused by such removal.
9. Fire Insurance. Tenant shall not permit any use of the Premises which will make
voidable any insurance on the property of which the leased Premises are a part, or on the
contents of said property or which shall be contrary to any law or regulation. Tenant shall on
demand reimburse Landlord all extra insurance premiums caused by Tenant's use of the
Premises.
2
1768337
10. Tenant Insurance. Tenant, at its sole cost and expense, shall obtain and maintain
in effect at all times during the term of this Lease, policies providing the following coverage and
shall furnish Landlord with a certificate showing such insurance to be in force upon the
commencement of the term.
A. Tenant's work and contents: All goods and personal property of every kind, in
and upon the Premises, shall be at the sole risk and hazard of the Tenant, or those claiming by,
through or under Tenant, or the owner thereof. Policies of insurance coverage, Tenant's fixtures
and equipment installed and located on the Premises, including without limitation, all leasehold
improvements installed by Tenant, and in addition thereto, covering all of the furnishings,
merchandise and other contents in the Premises insuring against any and all perils included
within the classification "fire and extended coverage" under insurance industry practice in the
jurisdiction in which the Property is located.
B. Liability Insurance: Tenant agrees to protect, indemnify and save harmless
Landlord, when required, of and from any and all claims from injury to personal property by
reason of any accident, or happening in, upon, or about the Premises, and Tenant agrees to carry
public liability and property damage insurance.
11. Security Deposit. Intentionally deleted.
12. Assignment and Subletting. Tenant shall have no right to sublet the Premises or
assign its interest in this Lease or in the Premises without Landlord's prior written consent.
Notwithstanding such consent, Tenant shall remain liable to Landlord for the payment of all rent
and for the full performance of the covenants and conditions of this Lease.
13. Indemnification and Liability. Tenant and its respective successors and assigns
agrees to defend, indemnify and hold harmless Landlord, and its respective successors and
assigns, from and against any and all costs, losses, claims, liabilities, fines, expenses, penalties,
and damages (including reasonable legal fees) in connection with or resulting from any injury or
damage to the Premises or third parties caused by Tenant or its employees, agents, or invitees
during the Term. Removal of snow and ice from the sidewalks bordering upon Tenant's
Premises shall be Tenant's responsibility.
14. Default. Tenant shall be deemed to be in default under this Lease upon
occurrence of any of the following events: (a) any failure of Tenant to pay any sum of money
due hereunder within ten (10) days after written notice, (b) any failure of Tenant to perform any
other of the terms, conditions, or covenants of this Lease for more than thirty (30) days after
written notice of such default shall have been received by Tenant, or (c) Tenant shall be declared
bankrupt or insolvent according to law, or, if any assignment shall be made of Tenant's property
for the benefit of creditors. Upon the occurrence of any of the events of default described above,
Tenant shall be deemed to be in default of this Lease, and Landlord shall have the remedies
described as follows: Landlord shall have the right, while such default continues, to re-enter and
take complete possession of the Premises, to declare the term of this lease ended, and remove
Tenant's effects. Tenant shall indemnify Landlord against all loss of rent and other payments
which Landlord may incur by reason of such termination during the remainder of the term.
Landlord shall have the right, but not the obligation, to remedy such default for the account and
1768337
at the expense of Tenant, it being understood that the default shall not be deemed waived. If
Landlord makes any expenditures or incurs any obligations for the payment of money in
connection therewith, including but not limited to, reasonable attorney's fees such sums shall be
paid or obligations insured with an interest rate of 10% per annum and costs shall be paid to the
Landlord by the Tenant as additional rent.
15. Subordination. This Lease shall be subject and subordinate to any and all
mortgages, deeds of trust and other instruments in the nature of a mortgage, now or at any time
hereafter, a lien or liens on the property of which the leased Premises are a part and the Tenant
shall, when requested, promptly execute and deliver such written instruments as shall be
necessary to show the subordination of this lease to said mortgages, deeds of trust or other such
instruments in the nature of a mortgage.
16. Landlord's Access. Landlord or its agents may, at reasonable times, enter to view
the Premises and may remove placards and signs not approved and affixed as herein provided,
and make repairs and alterations as Landlord should elect to do and may show the Premises to
others, and at any time within three (3) months before the expiration of the term, may affix to
any suitable part of the Premises a notice for letting or selling the Premises or property of which
the Premises are a part and keep the same so affixed without hindrance or molestation.
17. Surrender. At the expiration or other termination of this Lease, Tenant shall
remove all its goods and effects from the Premises (including all signs and lettering affixed or
painted by Tenant, either inside or outside of Premises). Subject to Section 6 above, Tenant shall
deliver to Landlord the Premises and all keys, locks, and other fixtures connected therewith and
all alterations and additions made to or upon the Premises, in good condition, damage by fire or
other casualty only excepted. In the event of Tenant's failure to remove any of its property from
the Premises, Landlord, without liability to Tenant for loss or damage thereto, and at the sole risk
of Tenant, may remove and store, retain under Landlord's control, and/or sell at public or private
sale any or all of Tenant's property not so removed and apply the net proceeds of such sale to the
payment of any sum due hereunder, or to destroy such property.
18. Notices. All notices or demands required or permitted to be given or served
pursuant to this Lease shall be in writing (except as otherwise expressly provided herein) and
shall be deemed to have been given or served when received or refused, if sent by United States
registered or certified mail, postage prepaid, via facsimile, or by nationally recognized overnight
courier, and addressed to either party at the following addresses:
If to Landlord:
Jennifer & Edward McDonald
65 Rhodes Street
Plainville, MA 02762
If to Tenant:
Aaron Thomas Rampello
54 Colburn St
North Attleboro, MA 02760
Such addresses may be changed from time to time by either party by serving notice as above
provided.
0
1768337
19. Force Maieure. In the event Landlord is prevented or delayed from making any
repairs or performing any other covenant hereunder by reason of any cause reasonably beyond
the control of Landlord, Landlord shall not be liable to Tenant nor, except as expressly otherwise
provided in case of casualty or taking, shall Tenant be entitled to any abatement or reduction of
rent by reason thereof, nor shall the same give rise to a claim by Tenant that such failure
constitutes actual or constructive eviction from the Premises or any part thereof.
20. Late Charge. If rent or any sum payable hereunder remains outstanding for a
period of ten (10) days, Tenant shall pay to Landlord a late charge equal to one and one-half
percent (1.51/o) of the amount due for each month or portion thereof during which the arrearage
continues.
21. Holdover. Should Tenant continue to occupy the Premises after expiration of the
Term and any extensions thereof, without Landlord's written consent, Tenant shall be deemed to
be occupying the Premises on a month-to-month basis on the same terms and conditions of this
Lease, except that Tenant shall pay Landlord monthly rent in an amount equal to two hundred
percent (200%) of the Base Rent in effect immediately before the expiration of the Term.
Notwithstanding the foregoing, if the parties are working in good faith to extend the
Lease, Landlord will not charge Tenant any holdover amount for the first three months of
holdover. Should the parties reach an agreement on the lease extension, the agreed upon Base
Rent for the extension period, if higher than the Base Rent in place at the time of the Lease
Expiration, will be retroactive to the date the Lease expired. In the event that Tenant requires a
short term month to month extension, not to exceed three months, Landlord, at its election, shall
have the right to increase the Base Rent by an amount of up to 10%.
22. Fire• Casualty' Eminent Domain. In the event of damage to, fire, or destruction
of, any portion of the Premises, the Building or access thereto or if the Premises or Building shall
be taken by eminent domain, Landlord may elect to terminate this Lease. A just and
proportionate abatement of rent shall be made, and Tenant may elect to terminate this Lease if
within thirty (30) days, Landlord does not provide Tenant written notice of its intent to restore
the Premises or Landlord within ninety (90) days fails to restore the Premises to a condition
substantially suitable for their intended use.
23. Brokers. Landlord and Tenant hereby represent and warrant to one another that
neither party nor their respective officers or agents nor anyone acting on their behalf has dealt
with any real estate broker in the negotiation or making of this Lease. Both Landlord and Tenant
agree to indemnify and hold one another harmless from the claim or claims of any broker or
brokers claiming to have caused the parties to enter into this Lease.
24. Binding Effect. This Lease shall be binding upon and shall inure to the benefit of
the parties hereto and their respective beneficiaries, successors and assigns.
25. Quiet Enioyment Entry into the Premises. Landlord covenants that so long as
Tenant is not in default hereunder after the expiration of any applicable cure periods under this
Lease, Tenant shall have quiet and peaceful possession and enjoyment of the Premises and shall
1768337
not be interfered with by Landlord, or any party claiming by, through or under Landlord or any
party claiming title superior to Landlord.
26. Attomeys' Fees. All reasonable attorneys' fees, including actual expenses and
court costs, incurred by the prevailing party to enforce the terms of this Lease against the non -
prevailing party shall be paid by the non -prevailing party.
IN WITNESS WHEREOF, the parties hereto have caused this Lease to be duly executed,
pursuant to proper authority duly granted, as of the date first above writty en.
1768337
LANDLORD:
By:
Name:
TENANT: Aaron Thomas Ram�ell0
By: �>
Name-.�
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:
JAIME CARLETON
Permit Number: 11
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
located at
Tattooing IV Body Piercing I. 'Both
MASTER'S METHOD TATTOO, INC.
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPR/AED - Adult Certificate expires: 4/912019
Bloodborne Pathogens Certificate expires: 811012018
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires onDecember 31, 2017 unless sooner suspended or revoked.
MANSFIELD BOARD OF HEALTH
MichaeCMcCCean, Chairman
September 27,2017
To Whom It May Concern,
I highly recommend Jaime Carleton for Body Art Practitioner/Body Piercer license at
Master's Method Tattoo, Inc. in Mansfield, MA.
Jaime has apprenticed with me learning Body Piercing techniques and procedures,
familiarizing herself with all Body Piercing tools and jewelry. I have trained her in the
correct grade of jewelry and materials that meet F-136 standard implant grade, proper
setups and breakdowns of piercing procedures, proper care and use of an UltraSonic
Cleaner, proper care and use of an Autoclave, proper sterilization of body piercing tools
and jewelry, how to properly dispose of waste, proper sterilization and cleaning
techniques, the prevention of cross contamination/infection prevention, body piercing
aftercare as well as customer service and shop management.
Jaime started her apprenticeship with me in February 2014 at Etched in Flesh and
continued over to Master's Method Tattoo, Inc. Jaime helped run Etched in Flesh until it's
closing in 2015 and is now the Shop Manager at Master's Method Tattoo, Inc., which she
has half ownership of, and helped facilitate that the shop met the town of Mansfield's Board
of Health regulations, and helps to ensure that the shop is always following all state and
town safety protocols and regulations as well as OSHA safety regulations. Jaime is in charge
of day to day operations such as cleaning, sterilizing, and making sure there is a list of items
that need to be ordered and is in charge of the ordering of jewelry and body piercing
supplies.
Jaime obtained all her knowledge of body piercing through hands on tasks and observation.
She observed setups and breakdowns, sterilization procedures, speaking with clients in
person and on the phone, piercing consultations, signing clients in and going over the
disclosure statement and consent forms as well as going over the health history paperwork
and evaluating it to determine if the client has any issues that would prevent them from
being able to get the procedure done or if there are any precautions that need to be taken.
While observing, Jaime also had verbal teachings from me on the proper piercing tools,
correct needle gauge, piercing trajectory, functional piercings, proper jewelry, skin
preparation, piercing procedures, jewelry changes, proper care and use of an UltraSonic
Cleaner, proper care and use of an Autoclave, proper sterilization of body piercing tools
and jewelry, how to properly dispose of waste, proper sterilization and cleaning
techniques, the prevention of cross contamination/infection prevention and verbally
informing the client of aftercare. Jaime has approximately 320 hours of observation.
Jaime has approximately 7,200 hours of hands on experience with talking to the client,
doing piercing consultations, going over the health history paperwork and body piercing
disclosure statements and the policies and agreements disclosure statement and evaluating
To Whom it May
I Jaime Carleton t
1
Jaime Carleton
Master's Method Tattoo
774-719-2821
12/6/2018
Commonwealth of Massachusetts
Town of Mansfield ToWn
6 P rkoRfoMansfield
Board of Health Mansfield, MA 02048
Practitioner's Permit for Offering Tirttoo or Body piercing
This is to certify that.,
JASON G. MORETTI
Permit Number.• 16
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing 1 7 Body Piercing 1.; Micropigmentation
located at:
MASTER METHOD TATTOO
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPR/AED -Adult Certificate expires: 3120/2020
Bloodborne Pathogens Certificate expires:
3/24/2020
i
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires onDecember 31, 2018 unless soonersuspended or revoked,
MANSFIELD BOARD OF HEALTH
-Vichaet'mcctean, Chairman
/✓f4�
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: Mo
Please
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH:RESIDENCE ADDRESS:
ADDRESS:
CITY:
MAILING ADDRESS:
CITY:
(A practitioner shall be a minimum of 18 years of age.)
STATE: Yom- ZIP: a I 6 1
STATE: ZIP:
PHONE NUMBER OF OPERATOR: �(�1
EMAIL OF OPERATOR: 1__TVN�10/S
PLACE OF EMPLOYMENT AS A PRACTITIONER�'flt
CITY: VBftfl/ Lry-l_. STATE: V -V(%`-, .. ZIP: -Vge-U
PHOFF
UMBER OF ESTABLISHMENT:
TYPEPRACTI
PHONE
PERMIT APPLYING FOR: (Check all that apply)
Tattooing ❑ Body Piercing n ' ❑ Micror�Cp�igmentation
PROJECTED DATE FOR BEGINNING OR RENEWAL: __1� �1�GV1 _ ..-.-
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 CPR/AED - Adult Certificate expires:
Preventing Disease Transmission andlor 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 (nla rot fenewals)
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 Board.r
Signature:-- — Date: - 1- l2 L —
FEE: $100.00
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.
Sigi atu ee of Individual or Corporate Name
�t
C>"
**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.
R.\HmIth\J n&s Doo=mts\PERMn APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commdnweaftk of1VlassachuseNs
Depm4ment of fndustrial Accidents
1 Congress Sd'e4 Suite 100
Boston, AM 02 11 4-2 01 7
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Warkers' Compensation Insurance Affidavit, General Bustriesses.
TO BB 1111,60 WITH THE PERMITTING AUTHORITY.
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Business/Orgmization Names -h; u �_` --�+t V rt � � ��{1 C
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Business IWO (required):
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Expiration Date:
g the policy number and expiration date).
d. to the imposition of criminal penalties of a
ie form of a STOP WORK ORDER and a fine
eat may be forwarded to the Office of
City of Framingham
Department of Public Health IV
Publiciieaitit
Board of Health
Laura T. Housman, MPH —chair Mailing Address; I50 Concord Street, Framingham, MA 01702
Michaet R. Hugo, Esq. — Vice Chair Physical Address 31 Flagg Drive, Door 414, Framingham, MA 01702
Tammy C. Harris, M0, MPH —Secretary ofrrce Telephone: (508) 532-5470
David W. Moore, MD Office Fax: (508) 532-5760
Judith Wester, RN, BSN, MSN office Emalk fvrlaithl.7rfra ninxhaner to auv
Direc ar of Public Health: Samuel S, Wong, Phi)
Tuesday, July 31, 2018
$50.00
In accordance with regulations promulgated under authority of Chapter 94, Section 350 A and Chapter III,
Section 5 of the Massachusetts General Laws a Permit is hereby granted to:
Jason Moretti
Whose Place of Business is: 247 WORCESTER RD
For: TATTOO ARTIST
tions If Anv:
To Operate in the CITY OF FRAMINGHAM
This permit expires Friday, May 31, 2019
BOH 160276
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Samuel Woug PhD ddb.
Director of Public Health
TOWN OF FRAMINGHAM
DEPARTMENT OF PUBLIC HEALTH
Thursday, May 12, 2016
BOARD OF HEALTH
Michael R. Hugo, Esq.
David W. Moore, M.D.
Laura Housman, M.P.H.
$50.00
In accordance with regulations promulgated under authority of Chapter 94, Section 350 A and
Chapter III, Section 5 of the Massachusetts General Laws a Permit is hereby granted to:
Jason Moretti
Whose Place
For: TATTOO AR
r
tions IfAnv:
To Operate in the TOWN OF FRAMINGHAM
This permit expires Wednesday, May 31, 2017
BON160276
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To Whom it May Conern,
I Jason Moretti decline the Hepatitis B Vaccination.
Jason
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Mansfield, MA 02048
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Practitioner's Appliccation.ftrr Offering Body Art Services
OPERATOR NAME: D&C -1 k-+ Vy
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH o ./v ,1jg9 (A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS:: /g/ G(elj011i Gr.< S-74
CITY PIVVc ae,e,OCA _. _._._ _ STATE: /`p/� Z_ ZIP:
MAILINGG ADDREE,S//S: 1-.
CITY: rl-pv'cle."Ce
STATE: % ( ZIP: (f) 6
PHONE NUMBER OF OPERATOR: 60 Y � C�S • / / f-�
EMAIL OF OPERATOR: 'Oeci' x
PLACE OF EMPLOYMENT ASA PRACTITIONER: �fqc ivs vGL/,cr>%l a y/
ADDRES/S:4� n//ares 'Ar -4i' , 4't
CITY: /Y/%CA/i &'4 L,,,I STATE: A1i4.p zip: o � G /(/F
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PHONE NUMBER OF ESTABLISHMENT: ,J--1_ • 7/9_'_r2 0 a. (.
TYPES OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply
R Tattooing ❑ 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 doc€trrtentatior)
First Aid and CPR Certifications for tattoo and piercing
American Red. Cross Standard First Aid Certificate expires:
American Red Cross CPRIAED - 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
Heleatitus 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 (n/a forranowals)
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 vatic) from the date of issuance and shall expire on the last day of the year of issuance
unless revoked sooner by the .Board.
Signature
Date: yl /�7�%
FEE: $100.00
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1344-1729034
Issued To: Janggen, Dean
1112 Normandy Drive
Miami Beach, FL 33141
Mail To: Dean Janggen
1112 Normandy Drive
Miami Beach, FL 33141
Owner: Janggen, Dean
Tattooing Artist License
Tattooing -Artist
13 -BID -3324522
County: Dade
Amount Paid; $80.00
Data Paid: 12/28/2018
Issued Date: 1212812016
Expires On: 12/27/2017
Issued By:
Department of Health in Dade County