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Rectify Barbershop & Beauty Alcove - 12/31/2021
004 Town of Mansfield Town of J111 ansfzeld - Board of Health � 8 Park" Rpw Maffsfield,`8QA 02048 :. , Application for Offering Body Art Services � � �� ESTABLISHMENT NAME: hi ADDRESS: , / CITY: STATE:jjkV ZIP: PHONE NUMBER OF OPERATION: �hh'L'�_C,�j _ qq3 NAME OF OWNER Ska i1 Iv'1 �t'�Q I IJIa /t YY- a - ADDRESS: CITY: STATE n4H. ZIP:�t�_ PHONE NUMBER OF OWNER: EMAIL OF OWNER: S;h LuiIylr;'")1 bm- d CAI • (d/r 1 NAME OF CORPORATION / ASSOCIATION 4ARTNERS 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 I N ju(p-e Cws�l&n-� GrmS Sl L-; -�4 are- 0-ur-r 18, ADDRESS TOTAL SIZE OF OPERATION IS: el 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) Ajury and/or Complication Report (blank) OR IF RENEWAL, RENEWAL DATE —6isclosure Statement V exposure Incident Report (blank form) ,JKfection 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 Establish nts made under the authority of M.G.L. c.111 § 31. la Signature of establishment wrier Date Print me of establishment owner FEE: $200.00 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT iprvlu ntass.gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: cJ LA `U M UI yil_ Phone k ` / / I] Are yXan employer? Check the appropriate box: Business Type (required): 1. M 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 T ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care i' f with no employees. [No workers' comp. insurance req.] 12. [ Other C 6S(TIQ 7� ( rlt LLB %VtGI -Any applicant that ebecks box #1 must also fill out the section below showing their workers' compensation policy i1donnation. (J *'RIf the corporate officers have exennpted themselves, but the corporation has other ennployees, a workers' compensation policy is required mid such an organization should check box 91. I ani an employer tliat is providing workers' compensation insurance for nip eniplovees. Below is the policv information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. 4 L <A -A tp� 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 and 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 tortm 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,dia TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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 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. Q\Users\sleite\Desktop\Scotts Docnmeuts\Food Establishments- Temp\TAX. CERTIFICATION FORM.doc 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: Rectify Barbershop & Beauty Alcove Site location : 90 Copeland Drive Mansfiled, MA 02048 Type of Body Art Facility: Micropigmentation Contact Person: Shalyn Gamba Telephone: Date of Plan Signature Body Art Facility Infection Prevention and Control Plan A. Decontamination and Disinfection: Describe the procedures for decontaminating and disinfecting of workstation and surfaces 1. Workstation surfaces/countertops: All Work stations will be cleaned up by throwing away all items that can go into the waste basket. Any gauze with blood on them will be thrown out in the correct biohazardous can. Then the station will be completely wiped down with EPA germicidal wipes. 2. Workstation chairs/stools: All surfaces will be wiped down with a EPA germicidal wipes and new bed paper will be replaced for each client. 3. Trays: All Trays are to be disinfected with EPA germicidal wipes. All surfaces and legs are to be completely wiped down. 4. Armrests: All parts of the arm rest (under and over) are wiped down with EPA germicidal wipes. 5. Headrests: Wiped down with EPA germicidal wipes 6. Procedure area: Wiped down with EPA germicidal wipes 7. Tables: Wiped down from top to bottom with germicidal wipes 8. Tattoo machine and Clip Cord: Machine is to be wiped down along with the cord with EPA germicidal wipes. Then wrap the machine and cord in a fresh wipe until next client. 9. Reusable instruments, calipers, needle tubes, etc. portable light fixtures or other: All reusable instruments are to be wiped down with EPA germicidal wipes as well as all portable light fixtures. B. Reusable Instruments or Disposable: Describe the procedures used for decontaminating, sterilizing, packaging and storing of reusable instruments. Include the procedures for labeling of sterilized peel -pack. Indicate whether the body art facility uses all pre -sterilized, single -use and disposable instruments. Describe the record keeping logs and procedure logs maintained on -site when using 100% pre -sterilized, single -use and disposable instruments. 1. Needle tubes: We do not use these items 2. Calipers: We do not use this item 3. Other instruments: The machine hand piece is to be wiped down and wrapped in a EPA germicidal wipe. The hand piece must stay wrapped for a minimum of 5 minutes before next use. The hand piece is to be stored in the marked covered plastic bin kept in designated cabinet drawer. We use all single use needles and hand tools. For every client, the needle and hand tool lot number, manufactured date and exp. Date must be recorded on clients consent form and filed away in designated file cabinet. Body Art Facility Infection Prevention and Control Plan C. Storage: Describe the storage location and equipment used for the storage of clean and sterilized instrument peel packs to protect the packages from exposure to dust and moisture Storage for machine hand piece is a marked plastic container with lid. The container is to be stored in designated cabinet drawer. All disposable needles are kept in a marked plastic bin that is stored in cabinet. All Hand tools are kept in designated bins and stored in designated cabinet away from any moisture. D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing down the workstation for the following procedures Tattoo: perform hand hygiene. Put on protective equipment that is appropriate for the task. Cover the machine and machine cords with plastic coverings. Cover bottles used in procedure with protective plastic. Place bed paper over tattoo bed. Place barrier film on ring lights and parts of the cart that will be touched. Place all items to be used in the procedure on a set up area covered with clean dental bib (sterile needles, hand tools and other replaceable parts of the machine, pigment caps, gauze pads, paper towels, etc. ) Dispense pigments. Open the needle packages, hand tools and other sterile components in front of the client, and prepare the machine for applying permanent makeup. Don clean, previously unused, disposable examination gloves on both hands just prior to the procedure. Tear Down Procedure Remove needles from machine and hand tools and place them into the sharps container. Remove gloves. Preform hand hygiene. Give written and verbal aftercare instructions to client and answer questions. Don fresh gloves and breakdown work station starting from the least contaminated areas to the most contaminated areas. Pull edges of the dental bib on the setup area and roll up the contaminated surface to the inside, and place into plastic lined trash receptacle for proper disposal: Throw away bed paper into trash receptacle. Non -regulated biohazard wastes are safely handled and stored. Remove gloves and preform hand hygiene. Don fresh gloves and decontaminate the counter, table, or tray where the clean field was set up. Decontaminate client chair or table with EPA approved disinfectant that kills HIV, hepatitis and tuberculosis. Remove gloves and other protective gear. Wash hands with soap and water. 2. Piercing: N/A 3. Branding: N/A Body Art Facility Infection Prevention and Control Plan E. Prevention of Cross Contamination: Describe the techniques used to prevent the contamination of instruments, tattoo machines, trays, tables, chairs, clip cords, power supplies, squeeze bottles, inks, pigments, (amps, stools, soaps, procedure sites and additional areas of potential contamination during body art procedures. Include barriers provided to prevent cross contamination. Describe how procedure sites are prepared for a body art procedures. All instruments are covered with a protective barrier film, and plastic. Each surface used during the procedures are covered with sanitary bibs and bed paper. Each area that would be touched during the service will be covered with barrier tape. All Bottles used will be covered with plastic bottle bags (single use) only. All pigment bottles MUST be kept of the tray during procedures. Pigments must be poured into a pigment cup at the sink, away from any blood contamination. Body art procedures are performed as described in section D E. Sharps Containers: Describe the procedures used for the safe handling of sharps and indicate the location of the in -use sharps containers. Indicate disposal frequency for sharps waste. Once you are done with the needles and hand tools you must dispose of them inside the proper sharps container located on the wall. Once the gallon container has become full replace it with a new one and mail out the used container in designated mail back container. These items are sent to a facility designed for medical waste. F. Sharps Disposal: Describe the disposal of sharps used during a body art procedure. 1. Needles and needle bars: Each used needle is placed in designated sharps container that is placed on the wall. 2. Razors: Body Art Facility Infection Prevention and Control Plan Razors are the be placed in the designated sharps container 3. Other sharps or single -use marking pens used on open skin: All other items that are single use are to be disposed of in appropriate sharps container G. List the Medical Waste Hauler, Mail -back System or Alternative Treatment Technology used for the disposal of sharps containers: Medical Waste Hauler: Street Address: City, State, ZIP: H. Sterilization of Jewelry: Describe the procedure used for the sterilization of jewelry prior to placing into newly pierced skin. We do not do piercing 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. We do not use a n autoclave, all of our hand tools are one time use. Machine base and hand piece are cleaned and wrapped in an EPA germicidal wipe. Scissors are tweezers are wiped with EPA germicidal wipes and then placed in sanitizing solution for 5 minutes. At the end of the day all tweezers and scissors are placed in the UV Sanitizer. J. Disinfection Products: List the disinfectant products used at the body art facility. Mckesson Germicid wipes, OPA metricide plus, Mckesson antimicrobial soa 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. Body Art Facility Infection Prevention and Control Plan Time: We do not use an autoclave Temperature: Psi: L. Personal Protective Equipment: List the personal protective equipment used during a body art procedure for the practitioner and the client. Gloves and face mask for practitioner. The clients are covered with a dental bib M. Handwashing Sink: List the locations of the hand wash sinks and describe the items supplied at each sink. Hand washing sink is installed in my room at the vanity. The sink is supplied with paper towels, antimicrobial soap and hand sanitizer. N. Aftercare Procedure: Describe the written recommendation and care information provided to the client after a body art procedure. List the type of bandages or wrapping provided after a body art procedure. Each client will be given an aftercare sheet for each procedure performed. Brow aftercare, eyeliner aftercare and lip aftercare. Please find each after care instructions in this packet. A liquid bandage is sprayed on the eyebrows after the procedure. Eyeliner and lips are protected with a barrier of auquafor. No bandages are needed. O. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when there is an accidental spill of sharps. If you encounter improperly disposed sharps in the work environment, handle them carefully. Keep your hands behind sharps at all times. Use a mechanical device to pick up sharps if they cannot be handled safely. Place the sharps back into a container and lock the lid. Wipe down all areas with EPA Disinfectant spray. Dispose of gloves and wash hands. P. Trash Receptacles and Disposal of Contaminated Trash: List the type of trash receptacles used and their location throughout the body art facility. Describe the procedure for the disposal of contaminated items, such as gloves. There are two different types of trash. One is located next to the sink and that is for general waste Body Art Facility Infection Prevention and Control Plan such as paper towels, gauze, dental bibs, bed paper and used gloves. Gloves are to be properly removed by turning them inside out. Second trash container is marked with a biohazard sticker and lined with biohazard bag. This is for contaminated gauze and any paper item used to soak up blood. This container is placed next to the practitioner tray. 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. We do not use Autoclave 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. Permablend pigments are used and we don't dilute the pigments. S. Service Animals: Describe the facility's policy regarding service animal presence in procedure, decontamination, and sterilization areas. We allow service dogs in procedure area but they must remain on the floor away from the treatment bed. Once the client has left the floor must be washed with proper floor cleaner. 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 and information contained in this document. To the best of my knowledge and belief, the statements made herein are correct and true. Signature: Title: Date: For Body Art Practitioners practicing at the establishment: I hereby certify that I 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. Art Facility Infection Prevention and Control Plan Signature: Title:--��t .� Date: Signature: Date: 100, Town of Mansfield - Bogard of Health OPERATOR NAME: Town of Mansfield 6 Park Row Mansfield, MA 02048 Please attach recent €dentification'photograph here (with head and shoulders, front view,) approximately 2x3 arches in size. Clear photocopies are acceptable. DATE OF BIRTH: RESIDENCE ADDRESS: CITY: urZ MAILING ADDRESS: CITY: PHONE NUMBER OF OPERATOR: L EMAIL OF OPERATOR: PLACE OF EMPLOYMENT AS A PRACTI ADDRESS: M CITY: PHONE NUMBER OF ESTABLISHMENT: (A practitioner shalt be a minimum of 18 years of age.) STATE: m 1_ ZIP: STATE: 116 P, ZIP: STATE: 'r- Zip: TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check atf that appfyf Tattooing ❑ Body Piercing P Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: �Gfi%n u rq o-Dad IF A TIME LIMITED EVENT, NAME AND ADDRESS OF E ENT: DATE OF EVENT: Plea�s/e �ttach 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 Bloodbome Pathogens Certificate expires: fse work /training on human anatomy (body piercing only) se work / training on skin diseases, disorders and conditions for tattoo and piercing titus 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 for renawats) 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. Signature: _✓J' v' a �— __— Date: FEE: $100.00 I'm Declining to take the Hepatitis B vaccine Shalyn Gamba OFAmerican Red Cross Certificate of Completion Shalyn Gamba has successfully completed requirements for Adult and Pediatric First Aid/CPR/AED conducted by American Red Cross Date Completed: 11/09/2019 Valid Period: 2 Years Instructors: Darrin Brown r-vc ;w Certificate ID: GYPODW To verify, scan code or visit: https://www.redcross.org/take-a-class/grcode? certnumber=GYPODW hops://wrww. red cross, o rg/fake-a-class/grcc d Oernail=Shal yng a mha%g0gmO,com&s el ect ed C e ris- id-OYP0DVV%2C&size=1185 0/16/20, 10'.'13 AM Page,1 of 2 a a -I S 0 n 0 a D_ 9 m D Exposure Event Number Sample Blood and Body Fluid Exposure Report Form Facility name: Name of exposed worker: Last First : ID #: Date of exposure: / / Time of exposure: AM PM (Circle) Job title/occupation: Department/work unit: Location where exposure occurred: Name of person completing form: Section I. Type of Exposure (Check all that apply.) ❑ Percutaneous (Needle or sharp object that was in contact with blood or body fluids) (Complete Sections Il, Ill, IV, and V.) Mucocutaneous (Check below and complete Sections Ill, IV, and VI.) Mucous Membrane Skin Bite (Complete Sections lll, IV, and Vl.) Section 11. Needle/Sharp Device Information (If exposure was percutaneous, provide the following information about the device involved.) Name of device: Unknown/Unable to determine Brand/manufacturer: Unknown/Unable to determine Did the device have a sharps injury prevention feature, i.e., a "safety device"? Yes No Unknown/Unable to determine If yes, when did the injury occur? ❑ Before activation of safety feature was appropriate ❑ Safety feature failed after activation During activation of the safety feature El Safety feature not activated safety feature improperly activated ❑ Other: Describe what happened with the safety feature, e.g., why it failed or why it was not activated: Section Ill. Employee Narrative (Optional) Describe how the exposure occurred and how it might have been prevented: NOTE: This is not a CDC or OSHA form. This form was developed by CDC to help healthcare facilities collect detailed exposure information that is specifically useful for the facilities prevention planning. Information on this Page WI ) may meet OSHA sharps injury documentation requirements and can be copied and filed for purposes of maintaining a separate sharps injury log. Procedures for maintaining employee confidentiality must be followed. Exposure Event Number_ Section IV. Exposure and Source Information A. Exposure Details: (Check all that apply.) 1. Type of fluid or material (For body fluid exposures only, check which fluid in adjacent box.) El Blood/blood products Identify which body fluid Visibly bloody body fluid` _ Cerebrospinal _ Urine _Synovial Amniotic _Sputum Peritoneal Non -visibly bloody body fluid" _Pericardial _Saliva _Semen/vaginal Visibly bloody solution (e.g., water used to clean a blood spill) _ Pleural _ Faces/stool Other/Unknown _ 2. Body site of exposure. (Check all that apply.) ❑ Hand/finger ❑ Eye Mouth/nose Face Arm ❑ Leg ❑ Other (Describe: ) 3. If percutaneous exposure: Depth of injury (Check only one.) ❑ Superficial (e.g., scratch, no or little blood) Moderate (e.g., penetrated through skin, wound bled) Deep (e.g., intramuscular penetration) Unsure/Unknown Was blood visible on device before exposure? El Yes No Unsure/Unknown 4. If mucous membrane or skin exposure: (Check only one.) Approximate volume of material Small (e.g., few drops) Large (e.g., major blood splash) If skin exposure, was skin intact? ❑ Yes ❑ No Unsure/Unknown B. Source Information 1. Was the source individual identified? ❑ Yes ❑ No Unsure/Unknown 2. Provide the serostatus of the source patient for the following pathogens. Positive Negative Refused Unknown HIV Antibody HCV Antibody ❑ El F-1 HbsAg ❑ ❑ 3. If known, when was the serostatus of the source determined? Known at the time of exposure Determined through testing at the time of or soon after the exposure Exposure Event Number Section V. Percutaneous Injury Circumstances A. What device or item caused the injury? Hollow -bore needle ❑ Hypodermic needle _Attached to syringe —Attached to IV tubing _ Unattached Prefilled cartridge syringe needle Winged steel needle (i.e., butterflyR type devices) _ Attached to syringe, tube holder, or IV tubing Unattached IV stylet ❑ Phlebotomy needle ❑ Spinal or epidural needle ❑ Bone marrow needle ❑ Biopsy needle Huber needle Other type of hollow -bore needle (type: ) Hollow -bore needle, type unknown Suture needle Suture needle Glass Capillary tube Pipette (glass) Slide Specimen/test/vacuum Other. Other sharp objects ❑ Bone chip/chipped tooth Bone cutter Bovie electrocautery device Bur Explorer ❑ Extraction forceps Elevator ❑ Histology cutting blade ❑ Lancet ❑ Pin Razor Retractor El Rod (orthopaedic applications) Root canal file Scaler/curette Scalpel blade Scissors ❑ Tenaculum ❑ Trocar ❑ Wire ❑ Other type of sharp object Sharp object, type unknown Other device or item ❑ Other: B. Purpose or procedure for which sharp item was used or intended. (Check one procedure type and complete information in corresponding box as applicable.) Type of Line ❑ Establish intravenous or arterial access (Indicate type of line.) _ Peripheral _ Arterial _ Central Other Access established intravenous or arterial line (Indicate type of line and reason for line access.) Reason for Access ❑ Injection through skin or mucous membrane (Indicate type of injection.) __ Obtain blood specimen (through skin) (Indicate method of specimen collection.), Other specimen collection Suturing Cutting ❑ Other procedure ❑ Unknown y - Connect IV infusion/piggyback Flush with heparin/saline Obtain blood specimen _ Inject medication Other: Type of Injection _ IM injection _ Epidural/spinal anesthesia _ Skin test placement _ Other injection Other ID/SQ injection Type of Blood Sampling Venipuncture _ Umbilical vessel Arterial puncture Finger/heelstick — Dialysis/AV fistula site _ Other blood sampling Exposure Event Number C. When and how did the injury occur? (From the left hand side of page, select the point during or after use that most closely represents when the injury occurred. In the corresponding right hand box, select one or two circumstances that reflect how the injury happened.) During use of the After use, before disposal of During or after disposal of item Other(Describe): Unknown Select one or two choices: _ Patient moved and jarred device _ While inserting needle/sharp _ While manipulating needle/sharp _ While withdrawing needle/sharp _ Passing or receiving equipment Suturing Tying sutures _ Manipulating suture needle in holder _ Incising _ Palpating/Exploring _ Collided with co-worker or other during procedure Collided with sharp during procedure Sharp object dropped during procedure Select one or two choices: _ Handling equipment on a tray or stand _ Transferring specimen into specimen container _ Processing specimens _ Passing or transferring equipment _ Recapping (missed or pierced cap) _ Cap fell off after recapping _ Disassembling device or equipment Decontamination/processing of used equipment _ During clean-up In transit to disposal _ Opening/breaking glass containers _ Collided with co-worker/other person _ Collided with sharp after procedure Sharp object dropped after procedure Struck by detached IV line needle Select one or two choices: Placing sharp in container: _ Injured by sharp being disposed _ Injured by sharp already in container _ While manipulating container _ Over -filled sharps container _ Punctured sharps container Sharp protruding from open container Sharp in unusual location: _ In trash _ In linen/laundry _ Left on table/tray _ Left in bed/mattress _ On floor _ In pockeUclothing Other unusual location Collided with co-worker or other person _ Collided with sharp Sharp object dropped _ Struck by detached IV line needle Exposure Event Number Section VI. Mucous Membrane Exposures Circumstances A. What barriers were used by worker at the time of the exposure? (Check all thatapply,) ❑ Gloves Goggles Eyeglasses Face Shield Mask Gown B. Activity/Event when exposure occurred (Check one.) ❑ Patient spit/coughed/vomited ❑ Airway manipulation (e.g., suctioning airway, inducing sputum) ❑ Endoscopic procedure ❑ Dental procedure ❑ Tube placement/removal/manipulation (e.g., chest, endotracheal, NG, rectal, urine catheter) ❑ Phlebotomy ❑ IV or arterial line insertion/removal/manipulation ❑ Irrigation procedure ❑ Vaginal delivery ❑ Surgical procedure (e.g., all surgical procedures including C-section) ❑ Bleeding vessel ❑ Changing dressing/wound care ❑ Manipulating blood tube/bottle/specimen container ❑ Cleaning/transporting contaminated equipment Other: ❑ Unknown Comments: Consent and Release Agreement for Micropigmentation/ Cosmetic Tattooing This form provides information to make an informed choice of whether or not to undergo a micropigmentation application. This is a process of inserting pigments into the basal cell layer of the epidermis. Although semi- permanent this is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to. Although micropigmentation is effective in most cases, NO guarantee can be made that a specific client and using a pencil or powder may still be needed. We have no control over what occurs during the healing process. Generally, the results are excellent. However, a perfect result after one session is not a realistic expectation. It is usual and advised to expect a touch up after the healing is completed. Allow 4-6 weeks for healing time (healing time may vary) Initially the color will appear much more vibrant or darker in the first few days. The color WILL lighten 30-50% from the first visit, during the healing time. Usually within 5-7 days your brows and eyeliner will lose 10-15% thickness, soften and look more natural. The pigment is semi -permanent and WILL fade over time and will need to be touch up through the years. Touch ups are usually performed every 1 to 2 years. If you have had your eyebrows previously tattooed and are interested in a cover-up/re-work, we cannot guarantee results for cases such as these and we must approve that your eyebrows are workable during consultation. In some cases where the previous work is too dark, dense, or discolored, tattoo removal will be highly recommended before we begin the cover-up/re-work. Previously tattooed areas and cover-ups will almost always require additional appointments for best results. 1 201 i.ip 3 op X ,}, , u , y ,� << I I ( Or, .:� i.(.?STIi)P1t,�ld,-a`A`)yls;.j • Pain: There can be a certain amount of discomfort or pain even after the topical anesthetics has been used. Anesthetics work better on some people than others. • Possible side effects: Minor and temporary bleeding, bruising and swelling. This should dissipate within 1- 5 days. Some people bruise or swell more than others. Ice packs may help reduce swelling. Those who are prone to cold sores may develop one following lip procedures. Proper pre and post care will be advised. • Infection: Infection is very unusual but occasionally occur. Areas treated MUST be kept clean and only freshly cleaned hands should touch the areas. See "after care" sheet for instruction on care • Uneven Pigmentation: This can result from poor healing, infection, bleeding, skin type, or many other causes. Your Follow up appointment will likely correct any uneven appearance. • MRI: Pigments used in micropigmentaion contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or cosmetic tattooing. • Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, prilocaine, benzocaine, tetracaine, and or epinephrine are used. If you are allergic to any of these, please inform your technician. • Asymmetry: Every effort will be made to avoid asymmetry but our facial features may not be symmetrical so adjustments may be needed during the follow up session to correct any unevenness Client Signature Da Artist Signature Date I am 18 or older Aftercare instructions have been explained to me and a copy has been given to me. I will follow the aftercare to the best of my ability. I will call my artist if I have any questions regarding healing. I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. I understand that any skin treatments such as Rentin A, Alpha Hydroxy, Glycolic Acids, laser hair removal, plastic surgery, and Botox or other skin altering procedures may result in adverse changes to my cosmetic tattooing I understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond your control and I will need to maintain the color with future applications. (Optional) I consent to Rectify Barbershop & Beauty Alcove to take and use before and after photographs for social media purposes. I understand that I will need more than one procedure to achieve my final goal. Touch- ups must be completed within 90 days of initial procedure in order to be considered a free follow-up. After 90 days touch-up fees will apply. u I acknowledge it is not reasonably possible to my artist to determine whether I might have an allergic reaction to the pigments or ointments used in this process. u I certify that I have read and understand the contents of this form. I understand the risks and involvement of this procedure(s). I have been given full opportunity to ask any questions I might have about the procedure. I authorize my artist to perform Micropigmetation on me today. Client Artist Signature Date Date Client Medical History Form Date of First Zip/Postal Code Email Last Phone Number Do you have or previously had any of the following, Check yes or No (all answers are confidential) History of MRSA YES NO Diabetes YES NO Allergic to metals YES NO Hepatitis A B C D YES NO Cancer YES NO Chemotherapy/Radiation YES NO Abnormal Heart Condition YES NO Alopecia YES NO Have you had any aspirin or blood thinners in the past week? YES NO History of cold sores? YES NO HIV YES NO Kidney Disease YES NO Pregnant or nursing YES NO Are you on any anti-inflammatories or steroids? YES NO History of skin disease? YES NO Have you had Botox in the past week? YES NO Please List all Medication you are currently taking: The information provided is accurate and complete to the best of my knowledge, and that Rectify Barbershop & Beauty Alcove is not responsible for complications arising from incorrect information. Client Signature ©2018 Rectify Barbershop & Beauty Alcove, LLC 4 Using your fingertips, gently wash the area with unscented soap (ex. Dove) morning and night, for 7 days. 1. Apply a very thin layer of the aftercare gel I have given you with a cotton swab 2 times a day for 7 days. 2. Avoid washcloths and scratching or picking at the tattoo during the healing process. (Healing time may vary) 3. Avoid hot tubs, steam rooms, public pools, long hot showers, sweaty exercise, or submerging the tattoo in water for the first 10 days. 4. Avoid direct sunlight or tanning beds far 2 weeks after receiving the tattoo. 5. Avoid putting makeup on the area for the first week. 6. Avoid facials, chemical peels, or microdermobrosion for4 weeks. Immediately following your procedure, the tattooed area will appear to be darker and bolder in color and more sharply defined. This can last up to a week after the treatment while the initial healing process takes place. The treated area may feel a bit like sunburn afterwards but there should be minimal discomfort, The complete healing process takes about 6 weeks, at which time the true color of the tattoo is evident. During this process, your tattoo will soften and tighten. Be patient, even if you think too much color has been lost, as your skin is still regenerating and naturally exfoliating. Wait at least 6 weeks to see the true color, as it seems to take on new strength, and it is only after 6 weeks that your touch-up/adjustment can be done. If you have any questions please feel free to contact me at rectrfybba@gmail.co I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST -PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. ©20 18 Rectify Barbershop C Beauty AICOX'e, 1_I.0 5 Temporary side effects from micropigmentation include but are not limited to: redness, swelling, puffiness, bruising, dry patches and tenderness. You should expect to lose approximately 113 of the initial color during the healing process. We have selected the optimal pigments for you with this in mind. In approximately six days it may appear too light. After about 10 days, the color will show more. It will appear softer when completely healed. Day by day healing and what to expect Day 1. The eyes will be swollen and sore, like you have been crying, with a heavier eye makeup look. For the first 3-4 days, the color is darker than it will appear when healed. Apply a light gloss of Aquaphor ointment sparingly to the treated areas with a clean fingertip. Too much ointment makes the swollen area too wet. Use the ointment in the morning and evening. A third application is fine if needed, but don't over use. Clean the eyes in the evening with clean water and a tissue. Day 2. The eyelids are swollen for a few hours after waling up, still with heavier makeup look. When you wake up, refresh the treated area with cool water. Tissue dry and re -apply ointment. The eyes will be swollen and sore but will get better throughout the day. In the evening, gently cleanse with cool water, tissue chy, and re -apply ointment. Day 3. Swelling decreases but is not gone entirely. There is a tight feeling. The top layers of skin begin to lift away. The soreness will become less as the treated area begins to exfoliate. A rough texture appears on the skin. Use a small amount of ointment if needed. Day 4. There is a pinching feeling. Some itching is normal as the skin begins to flake. When the eyeliner area begins to exfoliate, do not pick at it! Discontinue ointment. It will flake off with the movement of the eye. Day 5. Color is somewhat grayish and will take a few more days to clarify to full color. The pigmented area begins to shrink and soften in size and color over the next few days. Exfoliation completes. The color will appear a bit "frosty," but will clarify in a few days. Day 6. The color has lightened from its initial overly -dark appearance. For the next few days, the color may now be lighter than what the final color will be. Day 10. The final color begins to stabilize and show through. The color will continue to soften as the healing process completes. I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST -PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. 02018 Rectify Barbershop & Beauty Alcove, LLC Lip Micropigmentation Aftercare Lips pre -procedure: If you have any history of cold sores, fever blisters, or herpes simplex, you must contact your physician to obtain and take the proper prescription medication to prevent such outbreaks for at least 4 days before and after the procedure. Many physicians prescribe 12 capsules of 500mg Valtrex. Follow your physician's instructions -Apply ice for the first 2-24 hours to reduce swelling.® Keep moist with of Aquaphor ointment or Liprotek for the next 3-4 days, and then switch to lip balm or lipstick with an SPF of 15 or greater as the sun tends to fade lip color quickly. ® Lips may appear to have too much color in the days following the procedure. You may add makeup to soften the color. ® Scars on the lips from fever blisters cause pigment removal. Day 1. Swelling, tender, heavy, thick lipstick look with reddish brick color. For the first few days, the color is darker than it will appear when healed. Day 2. Slight swelling, reddish, tender, with a slight metallic taste. Day 3. Less swelling, thicker texture, sore, hot feeling before exfoliation with an orange color. Day 4. Exfoliation begins, very chapped lips. The color will become lighter as the epidermis sloughs off. It will appear that you have lost all of your color, however, when your lips have healed completely, the dermal layer will gradually become darker. Day 5. Very chapped but almost finished with first chapping stage. Day 6. A soft, rich color begins to appear. Days 7-13 Lip color disappears and the "frosty" 2nd chapping stage begins as a whitish gray haze on the lips. Day 14. Color blooms from within more and more each day until day 21 (3 weeks post procedure). Day 21. Healing complete. The color you see is the color that you have. Your lips will remain a bit dry for a month or two. Use a good lip balm and they will return to normal with full color. I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST -PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. ©2018 Rectify Barbershop & Beauty Alcove, LLC Employee's Report of Injury Form Instructions: Employees shall use this form to report all work related injuries, illnesses, or "near miss" events (which could have caused an injury or illness) — no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action. I am reporting a work related: ❑ Injury ❑ Illness ❑ Near miss Your Name: Job title: Supervisor: Have you told your supervisor about this injury/near miss? ❑ Yes ❑ No Date of injury/near miss: Time of injury/near miss: Names of witnesses (if any): Where, exactly, did it happen? What were you doing at the time? Describe step by step what led up to the injury/near miss. (continue on the back if necessary): What could have been done to prevent this injury/near miss? What parts of your body were injured? If a near miss, how could you have been hurt? Did you see a doctor about this injury/illness? ❑ Yes ❑ No If yes, whom did you see? Doctor's phone number: Date: Time: Has this part of your body been injured before? ❑ Yes ❑ No If yes, when? Supervisor: Your signature: Date: Supervisor's Accident Investigation Form Name of Injured Person Date of Birth Address City (Circle one) Male Female Telephone Number State Zip What part of the body was injured? Describe in detail. What was the nature of the injury? Describe in detail. Describe filly how the accident happened? What was employee doing prior to the event? What equipment, tools being using? Names of all witnesses: Date of Event Exact location of event: What caused the event? Time of Event Were safety regulations in place and used? If not, what was wrong? Employee went to doctor/hospital? Doctor's Name Hospital Name Recommended preventive action to take in the future to prevent reoccurrence. Incident Investigation Report Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.) This is a report of a: ❑ Death ❑ Lost Time ❑ Dr. Visit Only ❑ First Aid Only ❑ Near Miss Date of incident: This report is made by: ❑ Employee ❑ Supervisor ❑ Team ❑ Other Name: I Sec ❑ Male ❑ Female I Age: Department: Job title at time of incident: Part of body affected: (shade all that apply) Nature of injury: (most This employee works: serious one) ❑ Regular full time ❑ Abrasion. scrapes ❑ Regular part time ❑ Amputation ❑ Seasonal ❑ Broken bone ❑ Temporary ❑ Bruise Months with ❑ Burn (heat) this employer ❑ Bum (chemical) ❑ Concussion (to the head) Months doing ❑ Cushing Injury this job: ❑ Cut, laceration, puncture ❑ Hernia ❑ Illness ❑ Sprain, strain El Damage to a body system: ❑ Other Number of Written witness statements: Photographs: Maps / drawings: attachments: What personal protective equipment was being used (if any)? Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details. Description continued on attached sheets: ❑ Unsafe workplace conditions: (Check all that apply) ❑ Inadequate guard ❑ Unguarded hazard ❑ Safety device is defective ❑ Tool or equipment defective ❑ Workstation layout is hazardous ❑ Unsafe lighting ❑ Unsafe ventilation ❑ Lack of needed personal protective equipment ❑ Lack of appropriate equipment / tools ❑ Unsafe clothing ❑ No training or insufficient training ❑ Other: Why Why did the acts exist? Unsafe acts by people: (Check all that apply) ❑ Operating without permission ❑ Operating at unsafe speed ❑ Servicing equipment that has power to it ❑ Making a safety device inoperative ❑ Using defective equipment ❑ Using equipment in an unapproved way ❑ Unsafe lifting ❑ Taking anunsafe position or posture ❑ Distraction, teasing, horseplay ❑ Failure to wear personal protective equipment ❑ Failure to use the available equipment / tools ❑ Other: Is there a reward (such as "the job can be done more quickly", or "the product is less likely to be damaged") that may have encouraged the unsafe conditions or acts? ❑ Yes ❑ No If yes, describe: What changes do you suggest to prevent this incident/near miss from happening again? ❑ Stop this activity ❑ Guard the hazard ❑ Train the employee(s) ❑ Train the supervisor(s) ❑ Redesign task steps ❑ Redesign work station ❑ Write a new policy/rule ❑ Enforce existing policy ❑ Routinely inspect for the hazard ❑ Personal Protective Equipment ❑ Other: has been) done to carry out the suggestion(s) checked above? Description confirmed on attached sheets: ❑