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HomeMy WebLinkAboutArt & Soul Tattoo, LLC - 12/31/2021Tow,"f Mansfield a Town of Mansfield - Board of Health 6 Park Row, M69gpeld, MA'02048 N Fn na,t4�`nva j£ rv.,� f NOV Application for Offering Body Art Services ESTABLISHMENT NAME: A-v-A- -i- Soud 4--ho' ILL — ADDRESS: - ��fi //� �1n QUA 1� M r�1 / �`/ CITY: _ _CJ U \.mac/ (✓� L�,Y)-�1... _. r -_-) __.. �STATE 1 �.... ZIP: .... D�l�"V `1_ O_ PHONE NUMBER OF OPERATION: NAME OF OWNER ADDRE1S�S: 15)I/ ---La a'_� CITY: I"�w�5"tL�l STATE: Mfg ZIP - PHONE NUMBER OF OWNER_ _��O, X � %�/ & q EMAIL OF OWNER: /Gr._.t{-CQS.k2_ Gak; �9 NAME OF CORPORATION /ASSOCIATION / PARTNERS NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR MORE IN THE CORPORATION / ASSOCIATION / PARTNERSHIP: N/A--- PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED WITHOUT PROPER CONSENT 51zL� e or I ed� z�lC� 15�c v�i is re�c c(rzec �Gza c- c�vt t, 0 avI V1 `fM�y a re i_ _+. -- MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: TOTAL SIZE OF OPERATION IS: q l5y jL FT. PROJECTED DATE FOR BEGINNING OPERATION IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT � / I I - I Additional forms to be submitted: Client Application Informed Consent Form Drawing of the floor plan (n/a for renewals) e Injury and/or Complication Report (blank) OR IF RENEWAL, RENEWAL DATE e X SG( rvi e '-G rr)-) Disclosure statement o Exposure Incident Report (blank form) Infection Prevention and Control/ Exposure Control Plan and Employee Training Signatures Applicant Statement of Consent: 1 have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. c.111 § 31. 111tP6! 2-0 Signature of establishment owner Date Print name of establishment owner FEE: $200.00 Art & Soul Tattoo, LLC - EXPOSURE INCIDENT REPORT FORM 88 Copeland Drive - Mansfield, MA 02048 - 508-339-2001 - www.artandsoultattoo.net Date of Incident: Full Name: Phone #(s): Title: Description of Incident/Exposure (please print): Signature: Signature of Shop Owner/Manager: Date Mansfield Board of Health -Art and SOUL Tattoo, LLC. - Disclosure Statement This statement shall be given to all tattoo clients and must be signed prior to procedure. Tattoo Disclosure Statement Risks are associated with invasive procedures; these may include: Pain, bleeding, swelling, infection, scarring of the area and nerve damage. Unsterilized equipment and needles can spread infectious diseases; all equipment must be clean and sanitary before use. Tattoos are not easily removed and, in some cases, may cause permanent discoloration; carefully consider your risks when getting a tattoo. Allergic reaction must also be considered. The inks, dyes, pigments used for tattoos are color additives. Currently no color additives have been approved by the FDA. (Eternal Ink tests all of their pigments for safety. The MSDS report is on the Eternal Tattoo Supply website) Blood donations cannot be made for a year after tattoo procedures. The practitioner should: Properly/thoroughly clean the area before procedure, use sterilized equipment/sterile techniques, and provide information for aftercare. Health History and Informed Consent The following conditions may increase health risks associated with receiving body art: Being Pregnant; Diabetes; Hemophilia (bleeding); skin diseases, lesions, skin sensitivities to soaps, disinfectants, etc.; history of allergies, adverse reactions to pigments or other sensitivities; history of epilepsy, seizures, fainting, narcolepsy; use of medications such as anticoagulants (i.e., Coumadin: can thin blood and interfere with blood clotting); Hepatitis or HIV infection. I certify with my initials the following is true: Iam at least 18 years of age............................................................................................................ I am not experiencing any symptoms associated with Corona Virus/COVID-19 and also understand the risks .... I do not have: Heart condition, Hemophilia, Epilepsy, Diabetes, Hepatitis, Narcolepsy, Seizures, or fainting spells... _ I do not use: Anticoagulants, blood thinners, or any medications that interfere with clotting ........................ 1 am not HIV positive or under the influence of drugs or alcohol............................................................... 1 do not have any mental, physical, medical impairment or disability that might affect me as a direct or indirect result of my decision to have any tattoo related work done at this time ............................................. Please list below & tell your artist if you have any allergies (latex, shellfish, mangos, coconut, etc.) I hereby release any and all person representing Art and Soul Tattoo, LLC from any and all consequences that may be related to any tattoo related procedures applied by Art and Soul, LLC. I agree for myself, heirs, assigns, and legal representation to hold harmless from all damages, actions, and causes of action, any claim adjustments, cost of litigation, attorney fees as well as any and all costs and/or expenses which might arise from my decision to have any tattoo procedure done by Art and Soul Tattoo, LLC. Please print and present this form with your valid State ID or Passport: Name: Email: Address: City: State: Zip: Date of Birth: License ID #: Tattoo Design: Placement: By signing you are stating that all information entered is true/correct & you have read and understand all articles written above. Signature: X Date: Witness: Artist: COVID-19 LIABILITY WAIVER , acknowledge the contagious nature of the Corona Virus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. - I further acknowledge that Art & Soul Tattoo, LLC has put in place preventative measures to reduce the spread of the Corona Virus/COVID-19. - I further acknowledge that Art & Soul Tattoo, LLC cannot guarantee that I will not become infected with the Corona Virus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Corona Virus/COVID-19 may result from the actions, omissions or negligence of myself and others, including, but no limited to, shop staff and other shop clients and their families. - I voluntary seek services provided by Art and Soul Tattoo, LLC and acknowledge that I am increasing my risk to exposure to the Corona Virus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that: - I am not experiencing any symptoms of illness such as cough, shortness of breath/difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste and smell. - I have not travelled internationally within the last 14 days. - I have not traveled to a highly impacted area within the United States of America in the last 14 days. - I do not believe I have been exposed to someone with a suspected and/or confirmed case of Corona Virus/COVID-19. - I have not been diagnosed with Corona Virus/COVID-19 and not yet cleared as non -contagious by state or local public health authorities. - I am following all CDC recommended guidelines as much as possible and limiting my exposure to the virus. - I hereby release and agree to hold Art & Soul Tattoo, LLC harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the shop, or that may otherwise arise in any way in connection with any services received from Art and Soul Tattoo, LLC. - I understand this release discharges Art and Soul Tattoo, LLC from any liability or claim that I, my heirs, or any personal representative may have against the shop with respect to any bodily injury, illness, death, medical treatment, or property damage from Art and Soul Tattoo, LLC. This liability waiver and release extends to the shop together with all owners, partners, and employees. Signature Date '�angb�g:%��lu `�tighte.+tPaPa+nJzrai! Eternal Ink SECTION 1 — CHEMICAL PRODUCT AND COMPANY IDENTIFICATION PRODUCT NAME: Eternal Ink MANUFACTURER: Eternal Ink, Inc. 7987 Lochlin Drive Brighton, MI 48116 USA Telephone: 1-248-667-4060 SECTION 2 — COMPOSITION / INFORMATION ON INGREDIENTS Defined as non -hazardous by OSHA under 29 CFR 1910.1200(d) SECTION 3 — HAZARDS IDENTIFICATION PHYSICAL STATE: Liquid COLOR: Varies OSHA STATUS: While this material is not considered hazardous by the OSHA Hazard Communication Standard (29 CFR 1910, 1200), this MSDS contains valuable information critical to the safe handling and proper use of the product This MSDS should be retained and available for employees and other users of this product. EMERGENCY OVERVIEW: No known significant effects or critical hazards. Avoid prolonged contact with eyes. POTENTIAL HEALTH AFFECTS: Eyes, Skin, and Ingestion show no know significant effects or critical hazards. POTENTIAL CHRONIC HEALTH AFFECTS: Carcinogenic effects: No known significant effects or critical hazards. Mutagenic effects: No known significant effects or critical hazards. Teratogenicity/Reproductive toxicity: No known significant effects or critical hazards. Over -Exposure effects: None known. SECTION 4— FIRST AID MEASURES EYE CONTACT: Immediately Flush eyes with plenty of water for at least 15 minutes, occasionally lifting the upper and lower eyelids. Check for and remove any contact lenses. Get medical attention if irritation occurs. INGESTION: Wash out mouth with water. Do not induce vomiting unless directed to do so by medical personnel. Get medical attention if symptoms occur. SECTION 5 — FIRE FIGHTING MEASURES FLAMMABILITY OF PRODUCT: In a fire or if heated, a pressure increase will occur and the container may burst. PRODUCTS OF COMBUSTIOW Decomposition products may include the following materials: carbon oxides, nitrogen oxides. EXTINGUISHING: Use an extinguishing agent suitable for the surrounding fire. SECTION 6 — ACCIDENTAL RELEASE MEASURES Contain spill immediately. Inert materials such as sawdust may be applied to absorb the spilled material. Remove contained spill to an appropriate waste container for proper disposal. Soap and water may be used as needed. SECTION 7 — HANDLING AND STORAGE HANDLING: Put on appropriate personal protective equipment. Eating, drinking and smoking should be prohibited in areas where this material is handled, stored and processed. Do not ingest and avoid contact with eyes. Keep in the original container or an approved alternative made from a compatible material. Keep tightly closed when not in use. STORAGE: Store in original container protected from direct sunlight in a dry, cool and well -ventilated area. Keep container tightly closed and sealed until ready for use. Containers that have been opened must be carefully resealed and kept upright to prevent leakage. Do not store in unlabeled containers. Do not let freeze. SECTION 8 — EXPOSURE CONTROL I PERSONAL PROTECTION Respiratory protection is generally not required. Eye wash fountains should be available. SECTION 9 — PHYSICAL AND CHEMICAL PROPERTIES PHYSICAL STATE: Liquid COLOR: Varies BOILING / CONDENSATION POINT: 100OC (2120F) SOLUBILITY: Insoluble in the following materials: cold water and hot water. SECTION 10 - TOXICOLOGICAL INFORMATION ACUTE TOXICITY: No known significant effects or critical hazards. CHRONIC TOXICITY: No known significant effects or critical hazards. CARCINOGENICITY: No known significant effects or critical hazards. MUTAGENICITY: No known significant effects or critical hazards. TERATOGENICITY: No known significant effects or critical hazards. REPRODUCTIVE TOXICITY: No known significant effects or critical hazards. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tvivnwitass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEibly Business/Organizations 1, Name: am\ V � ��� Address: c� o p cA a_ rl d, b City/State/Zip:H(/�is, iL AL MS OV4 kre you an employer? Check the appropriate box: 1 )�j I am a employer with O employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]"' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] IA #: 54- Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 1O.❑ Manufacturing 11.❑ Health Care 12.gOther Tcie Uy applicant that checks box #L must also fill out the section below showing their workers' compensation policy information. 'If the corporate onicers have exempted themselves, but the cogturatiun has other employees, a workers' compensation policy is required and such an ganization should check box tll. am au employer drat is providbtg workers' comrpensation irnsaraiice for try employees. Below is the policy iuforination. snrance Company Name: i l "� \ e" !� � 4,t ' , i Ck { i � `� L. V L to l i 1 f' C ( 61 S t � (e I(' usurer's Address: ity/State/Zip: �'yf 1 1 �C� Ct �- L'c_i olicy # or Self -ins. Lie. yi �- ' � r'? �i � '� �" � Expiration Date: 2 L) 9- ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a lie up to $ t,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestieatims.of-the DIA for insurance eoveraee verification. do I....�e.— 50 -_ �-�z-- 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): f. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.ntnss.gov/dia Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY Liberty Mutual. INSURANCE POLICY INSURANCE AR INFORMATION PAGE . 175 BerlmleY Street 6oston, rdA02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-386428-010 Issuing Office 016C RENEWAL OF: WC5-31S-3864.28-019 issue Date Sub Account 04-27-20 Account Number 1-386428 000 1. Insured and Mailing Address ART AND SOUL TATTOO LLC RISK ID 000953803 88 COPELAND DRIVE NIANSFIELD, MA 02048 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 05-30-2020 to 05-30-2021 12:01 A.M. standard time at the insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: b Accident $ 100 , 000 each accident Bodily Injury y Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium Minimum Premium $ 189 (MA) Premium will be billed ANNUAL Producer-013766 C & S INSURANCE AGENCY INC PO BOX 406 MANSFIELD MA 02048 Total Estimated Annual Premium $ WC 00 00 01 A ©1987 National Councilonon Compensation Insurance,lnc. Ed.07101/2011 352 WC 00 00 01 B (CA) Page 1 of 1 Insured Copy G Body Art Facility Infection Prevention And Control Plan Guideline In accordance with the California Health and Safety Code, Section 119313, a body art facility shall maintain and follow a written Infection Prevention and Control Plan, provided by the owner or established by the practitioners, specifying procedures to achieve compliance with the Safe Body Art Act. A Copy of the Infection Prevention and Control Plan shall be filed with the Local Enforcement Agency and a copy maintained in the body art facility. The body art facility owner shall provide onsite training on the facility's Infection Prevention and Control Plan 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 Infection Prevention and Control Plan 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. Type of Body Art Facility: TA-7 7ZO Contact Person: ANNA f—f IC—Piifv�+p 22p t Telephone: Page 1 of 11 1 Body Art Facility Infection Prevention And Control Plan Guideline A. Decontamination and Disinfection: Describe the procedures for decontaminating and disinfecting of workstation and surfaces (California Health and Safety Code 119308 (b) and 119309 (a)(b)(c)(d)(e)). 1. Workstation surfaces/countertops: A J412 r. r`vaoC — / .MV A/Pw/.b! 2. Workstation chairs/stools: 3. Trays: sure. 4. Armrests: s a dal e. 5. Headrests: 6. Procedure area: 7. Tables: Page 2 of 11 Body Art Facility Infection Prevention And Control Plan Guideline d 8. Tattoo machine and Clip Cord: Sam_P 9. Reusable instruments, calipers, needo<ubes, etc, portable light fixtures or other: 10. Permanent Cosmetic Machine:, rn f a 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 (California Health and Safety Code 119309 and 119315). 1, NP.P./fIP. tnhps, 2. uanpers: 3. Other instruments: X{ U (_1e i /i 11 1 Page 3 of 11 W Body Art Facility Infection Prevention And Control Plan Guideline 10 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 (California Health and Safety Code 119315 (c)). Kp"-f ir) boxes -r Sfared or tnslde of- plaS+id Shelving, D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing down the workstation for the following procedures (California Health and Safety Code 119308, 119309 (c), 119311, and 119313 (b)(4)). 1. T.frnn- 2. Piercing: n la, 3. Permanent Cos etics: 4. Branding: 1y)0"eS an u1 . 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 l during body art procedures. Include barriers provided to prevent cross contamination. Describe how procedure sites are prepared for a body art procedures. (California health and Safety Code 119308, 119309, and 119311 (c)(d)(e)(f)). Dove ehan rrr as a, r� rim . 4- use 0-� M&3 w / pies l5ar(j arS r--e a�r� Cfa Page 4 of 11 Body Art Facility Infection Prevention And Control Plan Guideline E. Prevention of Cross Contamination (Contlnued): I I R 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 (California uo�ifh nnA 52nf t,, r.nria 11Q31d loll. G. Sharps Disposal: Describe the disposal of sharps used during a body art procedure (California Health and Safety Code 119308 (b)(3) and 119311 (g)). 1. Needles and needle bars: 92ie ivto G�¢s 4--bars oAx- huh r �er15 2. Raz rs: Mp S are Olt p6 I 3. Other sharps or single -use marking pens used on open skin: H. List the Medical Waste Hauler, Mail -back System or Alternative Treatment Technology used for the disposal of sharps containers (California Health and Safety Code 119314 (e)): M'0,4 rr�.,c"/7,.cMnScLLo �, t��s-r,'brake. /'Ylf} 78-1 — C?1.? - 6� Medical Waste HaWec Street Address: City, State, ZIP: Page 5 of 11 Body Art Facility Infection Prevention And Control Plan Guideline d I. Sterilization of Jewelry: Describe the procedure used for the sterilization of jewelry prior to placing into newly pierced skin (California Health and Safety Code 119310 (a) and 119315). n J. 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, such as Tergazyme (California Health and Safety Code 119309 (b)(e)(g). 119314 (c), and 119315. (b)). )nsirurr n�I,S C�rt in _ L lHmzon;r' kjlrlS+rvn enl sif ihs`t'oL� w A4r6i also. P , botooed + da4d Lgwl gun /'0 A,4 K. Disinfection Products: List the disinfectant products used at the body art facility (California Health and Safety Code 119301 (k) and 119308 (b)(6)). L. 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. Indicate whether each sterilization load is tested using Class 5 integrators (California health and Safety Code 119315 (b)(3)(5)). Time: 30 rn f n Temperature: 3 %0 Psi: M. Personal Protective Equipment: List the personal protective equipment used during a body art procedure for the practitioner and the client (California Health and Safety Code 119308 (a) and 1193090)). JOVeS L N. Handwashing Sink: List the locations of the handwash sinks and describe the items supplied at each sink (California Health and Safety Code 119�3114 (b)(3)). a eanM �_tnrz,r,er�tf,La1C'---tit0." Prt� /)iCC Page 6 of 11 Body Art Facility Infection Prevention And Control Plan Guideline O. 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 (California Health and Safety Code 119309 (a)(b)(c)). A-�-t-e-,rca r-o I yls-i W C:'1 oVl s 1112-1 IFEEW P. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when there is an accidental spill of sharps (California Health and Safety Code 119309 (a)(b)(c)). r-,lnved and car?�I-sharps ate �e�r�ed I� n_eIr + Q. 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 (California Health and Safety Code 119311 (a) and 119314 (d)). �3to Tras4 \s to -ea&)-1-ativo rasrn rn e d l e�asl e�Jis�osa P IL cs (} u e r-�o n-I-h I u R. 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 (California Health and Safety Code 119315 (b)(2)(4)). Pima, &nd t�\,)cy_n.o `ra'J k . Sp4e)s-� s o t� l opa d in ' ( I'ear, CD-CF- I-) t� V r . S. 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 (California Health f and Safety Code 119311 (b)(c)(d)(e)). -.L.v, iA Y D ,1 .' V _ Q'a"o /i J" , t" n'' _ v(O Sow Cups, Page 7 of 11 X, X Body Art Facility Infection Prevention And Control Plan Guideline T. Permanent Cosmetic Machine Name and Manufacturer: Provide the model name and number for the permanent cosmetic machine(s) used (California Health and Safety Code 119311 (i)Q)). o 1A, U. Service Animals: Describe the facility's policy regarding service animal presence in procedure, decontamination, and sterilization areas (California Health and Safety Code 119314 (f)). -A�CQnnot 6&Y no -io SeUI rC`e aV11Y1gajs UV\Vess T i.jan-+ ` 6 n hv-e wa(-A, Do-P-SVI4 o F l ev la �fi w e Ana u-e I t 2 Ch o f Ce-'W e CJ� S COS ,V V 14-1 Maintain a copy of this completed document in your files. Submit one copy to the Local Enforcement Agency. 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: Date Title: v /Pry-tl s+ Page 8 of 11 Town of Mansfield - Board of Health Pracddoner's Application for Offering Body Art OPERATOR NAME: Town of Mansfield 6 Park Row Mansfield, MA 02048 Ira 4� 03 �t11r1 Please attach recent identification photograph here (with head and shoulders, front viewjapproximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: I t -t f - (! TY - (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: ; 2-itILL � t) :g'"`\ 5f CITY: _ €"}'i f ^f �r".g'C'16� _ STATE: ZIP: MAILINGADDRESS: rz 6`7C's'A CITY:-i<--z%`v`"� PHONE NUMBER OF OPERATOR: EMAIL OF OPERATOR: STATE: MS r ZIP: �".,`_., y��� p PLACE OF EMPLOYMENT AS A PRACTITIONER: A 1r-j C,V)ii- ADDRESS: l j C, o f v,kC 4`\A A �t CITY: ._--° .` L'."--STATE: ., STATES 6 ZIP: -- PHONE NUMBER OF ESTABLISHMENT: —. _w TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) LY Tattooing M Body Piercing Mlcropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: i -I Ci'.% r 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 Bloodborne Pathogen Training Bloodbome 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 for renewals) Applicant Statement of Consent: I have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. 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: JL' FEE: $100.00 Y n W �\ iKL <rVIIi IIiV1/IYLKff,i f <Ia NJJNLIf LiJLffJ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation.Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �vr I + S­C�o Address: kre 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 2X 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 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, 51(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care f. ❑ We are a non-profit organization, staffed by volunteers, + 12.m Other 0e) with no employees. [No workers' comp. insurance req.] \ny applicant that checks box 81 must also fill out the section below showing their workers' compensation policy information. 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganization should check box fit. aar an employer that is p+•oviding workers' compensation insurance for my employees. Below is the policy information. Isurance Company Nan usurer's Address: ity/State/Zip: olicy # or Self -ins. Lic. Expiration [tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct 44 i_11 q 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 inwv.mass.gov/dia Phone TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. �.._...I .� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) OP- 6�-WL q "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\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 101'i4/2020 Hospital eTool - Healthcare Wide Hazards- Health Care Professionals Hepatitis B Declination Statement ni ilieify t a; CHifR t,p :i hs y , v j,1 Af-11Miv'f�;<¢ OSHA t, SHARE. NWN1.. Nevtcleuer ,_y RS5 !"ied5 Occupational Safety & Health Administration We Can Help What's New 1 Office s OSHA Home Workers Regulations Enforcement ! Data & Statistics Training Publications Newsroom I1 Small Business Anti -Retaliation << Back to Hospital eTool - Healthcare Wide Hazards - Bioodborne Pathogens Health Care Professionals Hepatitis B Declination Statement Hepatitis a Declination Statement` The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. Statement understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring iepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to re; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially ifectlous materials and I w of to be vaccinate with'h patitis B vaccine, I(wn receive the vaccination series at no charge to me. inployee Signature: I � r �� �'IDate: `Taken from: Bloodborne Pathogens and Acute Care Facilities, OSHA Publication 3128, (1992). .'adore sr n.. 7erat-rv3dH�.•;asy-„z. U.S. Department of Labor 1 Occupational Safety & Health Administration 1 200 Constitution Ave., NW, Washington, DC 20210 Telephone: 800-321-OSHA (6712) 1 TTY www.OSHA.gov https://www.osha.gov/SLTC/etoolsihospital/hazards/bbp/doelination.html 1/1 Town of Mansfield Town of Mansfield - Board of Health 9 Practitioner's Application for Offering Body Art Services OPERATOR NAME: Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: o(j L,?s/ _[qq(' _ (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: CITY:ul�,�`'__ STATE: _ZIP: — MAI LING ADDRESS: CITY: STATE: ZIP: PHONE NUMBER OF OPERATOR: $sq•-Is 3, 1(4(o3 EMAIL OF OPERATOR: �(4CCa_r rx rr•nsdl q PLACE OF EMPLOYMENT AS A PRACTITIONER: 0<4 � 5G w TG ADDRESS: bg copc LAND uPlie CITY: W\GNV5FIEL(J .STATE: __ ZIP: PHONE NUMBER OF ESTABLISHMENT: TYPE 9F PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) Tattooing EA Body Piercing 9 Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Please attach copies of appropriate documentation - First Aid and CPR Certifications for tattoo and piercing American Red Cross Standard First Aid Certificate expires: American Red Cross CPR(AED - Adult Certificate expires: Preventing Disease Transmission and/or Bloodborne Pathogen Training Bloodbome 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 for renewals) Applicant Statement of Consent: 1 have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. c.111 § 31. 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: t ___ Date: Q H dDp2f-� FEE: $100.00 v N O d �\ llfG VVLILIILVII IY4N4f I4 L f aI1 NJJNt.I//LJtIfJ Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation.Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: A(LT 50 U L 'TOYT00 Phone #: 31$' 33q ' a 00 i kre you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.9 I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for the in any capacity. g, ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]" I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 1 12.14 Other \ny applicant [hat checks box HI must also fill out the section below showing [heir workers' compensation policy mtormanun. 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganiaation should check box il1. aai an employer that is providing workers' eootpensation insurance foray eoployees. Below is the policy information. isurance Company Nan isurer's Address: ity/State/Zip: olicy k or Self -ins. Lic. Expiration ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia Phone TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Sign e of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) yos Us, 10 "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\Scotts Documents\Food Establishments- IempVFAX CERTIFICATION FORM.doc 10/14/2020 Hospital eTool - Healthcare Wide Hazards - Health Care Professionals Hepatitis B Declination Statement ti- r_ xrne,a , Cv_sru :•c:na c.:.i=t+ G� � z ? Ss 4,b4 us4Y_ OSHA 0 SHARE_,.. 91 V i I,,; �s7i:11'Sii'iHL'iYLi'7Neva51ettt: RSs seeds Occupational Safety & Health Administration We Can Help What'S New I Offices OSHA Home ! Workers Regulations Enforcement I;, Data&Statistics :; Training Publications Newsroom Small Business Anti -Retaliation ca Back to Hospital eTool -Healthcare Wide Hazards - Bloodborne Pathogens Health Care Professionals Hepatitis B Declination Statement Hepatitis B Declination Statement' The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. Statement understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring epatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to ie; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of cquinng hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially ife tious materials and 1 want to jle vaccinated with hepatitis B vaccine, II '!X can receive the vaccination series at no charge to me. // mployee Signature: Date: l0 ' t `'f —go 'Taken from: Bioodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). _e.c.esr;fae v ,.4.3s. asa��an Act i [4.ae� 'x.-:azenf i D[sLI ia.ass ; Y4eoarFe[rR §,`e4 S{t] Notices 1 r, mL.:I t35 U.S. Department of tabor I Occupational Safety & Health Administration 1 200 Constitution Ave., NW, Washington, DC 20210 Telephone: 800-321-OSHA (6742) 1 TTY www.OSHA.gov https://www.osha.gov/SLTCletools/hospital/hazards/bbp/declination.html 111 a. 000 p . o t � o o CD47 x 4m eq CD F CD 0 Q. 4 o U 3 K 1 ( -�33 500, Town of Mansfield Town ofMansfield - Board ofHealth 6 Park v Mansfield, MAQ2048 4` Practitionerrs Application for Offering Body Art.S"'eriices OPERATOR NAME: Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 i in size. Clear photocopies are acceptable. DATE OF BIRTH: 1-' %,-t5 1161 - - —+ (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: CITY: STATE: MA ZIP: MAI LING ADDRESS: CITY: �`/ STATE: ZIP: PHONE NUMBER OF OPERATOR: '-J �0 'I Z��' 4 I (0 0 EMAIL OF OPERATOR:----E/I 44'f/)c, ko 4,o v)IA PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: p () co pei� &VI C- /�y tt� II� CITY:-VA&.�(.._.... STATE:-2 -RA ZIP: -Dx7 PHONE NUMBER OF ESTABLISHMENT: _ SU�� 33g1,;WOJ TYPE (OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) Jul Tattooing Body Piercing 0 Micropigmentation PROJECTED DATE FOR BEGINNING OR RENEWAL: 11 1 1 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 CPRIAED - Adult Certificate expires: Preventing Disease Transmission and/orBloodborne 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 for renewals) Applicant Statement of Consent: I have recieved and read a copy of the Town of Mansfield Board of Health Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art Establishments made under the authority of M.G.L. 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 oo or by the B rd. //q Signature. C� lam`—� / . Date: FEE:$100.00 ITZ u 41� LL 0 w lid LZ § m TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name *'Social Security No. (Voluntary) or Federal Identification Nionber By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:AUsers\sleiteVDesktopAScott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 10/14/2020 Hospital eTool - Healthcare Wide Hazards - Health Care Professionals Hepatitis B Declination Statement A &'Ztf_nna: I [,-nkz hn., cm+ck'Jr OSHA `Q SHARE..._. �t)t�l,. �:Sl9.Ci,iLilii'iiBYiJNtd>leh RSS Feeds Occupational Safety & Health Administration We Can Help what's New I OfficesOSHA SHA Home Workers , Regulations Enforcement j', Data&Statistics Training Publications '+. Newsroom Small Business Anti-Retaliabon < Back to Hosp't I eT I ---Healthcare Wide Hazards - Bloodborne Pathogens Health Care Professionals Hepatitis B Declination Statement Hepatitis B Declination Statement" The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. Statement understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring iepabUs B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to ne; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis e, '�eTious disease. If, in the future I continue to have occupational exposure to blood or other potentially ofectious material nd 1 v nt be vaccinated with hepatitis B vaccine, Iran eceive the vaccination series at no charge tome. 0 Employee Sig atur ' —� Date: `Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). .:. o..cV:rr±r Lt(_.'..ir'FCprn.�,L7" Ea;.-ctY t:•�,:.:j S'ai ..ac.t% rt'ziuibt...�! t�npsrrnnk 54z.4 bat.. ,i.,ri,.ts t, te.k U,, U.S. Department of Labor I Occupational Safety & Health Administration 1200 Constitution Ave., NW, Washington, DC 20210 Telephone: 800-321-OSHA (6792) I TTY www.OSHA.gov https://www.osha.gov/SLTCletools/hospital/hazards/bbp/deelination.htmi 1/1 i i Remove bandage in one hour. Wash tattoo well with fragrance free soap and lukewarm water. Rinse with cold water. Air dry for 1045 minutes or gently pat dry with paper towel. No wiping. Apply a small amount of a fragrance -free lotion or Wild Rose Balm to tattoo until absorbed into the skin about 3-4 times a day or as needed until fully healed (1-3 weeks). Wash tattoo every time between reapplying lotion for first 5-7 days; after that stage the tattoo resembles dry skin. Tattoo may flake/peel like sunburn — keep moisturized. PLEASE DO NOT PICK OR SCRATCH TATTOO. DO NOT soak tattoo in shower, tub or ocean/pool or expose to direct sun or tan for 2-3 weeks. After tattoo has fully healed apply a high SPF to avoid sun damage. DO NOT use other products during healing process unless directed by your artist. If red bumps or a rash occurs you may be using too much lotion or allergic to what you are using. If swelling and redness persist please see a physician. The first touch-up is on us within the first year as long as the artist still works at Art & Soul. Please let us know if you have any questions: 88 Copeland Dr Mansfield MA - 508-339-2001 - Tues-Sat12-9pm www.aitandsoultattoo.net - tattoosbyanna @IiootmaiLconi - tattoosbvmull@icloud.com - ladysparrowtaftoos@yniail.co