HomeMy WebLinkAboutNew England Noir LLC - 12/31/2021300 ,0® 4'#6 lr 15
Town of Mansfield
Town of Mansfield - Board of Hea 6 Park Row
Mansfield, MA 02048
ESTABLISHMENT NAME: New Ern
it LLC
ADDRESS: 234 N. Main
CITY: Mansfield. _ STATE: MA. 2ip: 02703
PHONE NUMBER OF OPERATION:
NAME OF OWNER Albert Benjamin Thompson
ADDRESS: 168 Pleasant st #1
CITY: Attleboro. STATE: MA. zip:02703
PHONE NUMBER OF OWNER: 508-431 -4832 -
EMAIL OF OWNER: BenthompSontattooer@gmall.Com
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:
PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED
WITHOUT PROPER CONSENT Text
A consent form must be filled out prior to the procedure stating that the
Individual is 18 years of age or older. A valid picture ID must be provided to prove
_ ThP chants agp A photo copy will he ake If the In and saved for later reference
MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL:
168 Pleasant
TOTAL SIZE OF OPERATION IS:
FT.
PROJECTED DATE FOR BEGINNING OPERATION: 9/1 /2021 OR IF RENEWAL, RENEWAL DATE
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT
Additional forms to be submitted:
Client Application
Informed Consent Form
Drawing of the floor plan (n/a for renewals)
Injury and/or Complication Report (blank)
Disclosure Statement
Exposure Incident Report (blank form)
Infection Prevention and Control/ Exposure Control Plan
and Employee Training Signatures
Applicant Statement of Consent: I have recieved and read a copy of the Town of Mansfield Board of Health
Regulations for Body Art and understand the requirements of these regulations. I hereby apply for a license in
accordance with the provisions of the Town of Mansfield Board of Health Regulations for Body Art
Establishments made under the authority of M.G.L. CA 11 § 31.
- -a Albert Benjamin Thompson
�T
Signature of establishment owner Date Print name of establishment owner
FEE: $200.00
fdl SPf �••. V� rx--u rn �-"^..._
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: New England Noir LLC
Siteaddress: 234 N.Main St.
City, State, ZIP: Mansfield Ma 02048
Type of Body Art Facility: Tattoo Studio
Contact Person: Ben Thompson Telephone: 508-431-4832I
Date of Plan Review
Signature
Page 1 of 7
Body Art Facility Infection Prevention and Control Plan
A. Decontamination and Disinfection: Describe the procedures for decontaminating and disinfecting of
workstation and surfaces
1. Workstation surfaces/countertops:
Workstation surfaces are covered with a plastic barrier film prior to procedures to
prevent Cross contamination, then thoroughly wiped down with Madacide or
avid a wipes spray. oun er tops are whipped own With a aci a wipes spray
2. Workstation chairs/stools:
Workstation chairs /stools are whiped down with Madacide wipes/spray
before and after procedures
3. Trays:
Trays are whiped down with Madacide wipes/spray before and after procedures
4. Armrests:
Armrests are wiped down with Madacide wipes/sprav before and after
Procedures
5. Headrests:
Headrests are wiped down with Madacide wipes/spray before and after
Procedures
6. Procedure area:
Procedure ares are wiped down
with Madacide wipes/spray
7. Tables:
Tables are wiped down with Madacide wipes/spray before and after procedures
Page 2 of 7
Body Art Facility Infection Prevention and Control Plan
8. Tattoo machine and Clip Cord:
Tatton machine and rlip cord are wig clown with Madaride initials then covered
In a plastic barrier bag/sleeve which prevents cross contamination during procedui
The bag/sleeve is then disposed of after the procedure. Machine and cord are thel
VVIped down one final time.
9. Reusable instruments, calipers, needle tubes, etc. portable light fixtures or other:
Will have barrier film covering areas where I would need to touch them
while wearing gloves cluring procedures.
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:
time use only. uate ano metnoo of sterilization are Drinteq on peel i)aCK
2. Calipers:
N/A
3. Other instruments:
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 of needle cartridges is done in the drawers of our tool carts
Where they can avoid dust and moisture
Page 3 of 7
Body Art Facility Infection Prevention and Control Plan
D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing down
the workstation for the following procedures
1. Tattoo:Set up of the workstation starts with a sterilization of all surfaces with madacide, then plastic
barrier film is used to cover the surface. A tongue depressor is used to apply a small amount of
vaseline on the barrier next o the ink caps used to hold the ink. Gare is used during
breakdowns to prevent rmss contamination by bundling everything on the workstation up with
the barrier film and disposing of it. A final wipe down with madacide is the final step.
2. Piercing:
N/A
3. Branding:
N/A
E. Prevention of Cross Contamination: Describe the techniques used to prevent the contamination
of instruments, tattoo machines, trays, tables, chairs, clip cords, power supplies, squeeze bottles,
inks, pigments, lamps, stools, soaps, procedure sites and additional areas of potential contamination
during body art procedures. Include barriers provided to prevent cross contamination. Describe how
procedure sites are prepared for a body art procedures.
exception of chairs, inks. stools.. Green soap is distilled in squeeze bottle at
10 parts water to 1 part green soap. Bottles are wiped with madacide after
Barrier is taken off Stools,chairs are kept clean and dusted
on a regular basis and sterilized With maclacide when ink/tluia touches its
Sul face.
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.
Sharps containers (2) will be located and mounted on the walls
At each artists station. One medium sized sharps container can take 6
Months to a year to till. Sharps pick ups will be on an as neeaea basis
Page 4 of 7
Body Art Facility Infection Prevention and Control Plan
F. Sharps Disposal: Describe the disposal of sharps used during a body art procedure.
1. Needles and needle bars:
Disposable needle cartridges are dislodged from machine after procedures
ner
2. Razors:
Razors used for shaving area get thrown out in trash marked "biohazard"
Razors contaminated with blood get disposed in sharps container
3. Other sharps or single -use marking pens used on open skin:
No single use markina Dens get used on open skin
But in the event they do they get disposed of in bio trash
G. List the Medical Waste Hauler, Mail -back System or Alternative Treatment Technology used
for the disposal of sharps containers:
Medical Waste Hauler: Sharps Compliance, inc.
Street Address: 9220 Kirby Dr. #500
City, State, ZIP: Houston,Texas 77050
H. Sterilization of Jewelry: Describe the procedure used for the sterilization of jewelry prior to placing
into newly pierced skin.
I. Sterilization room: Describe the procedure used for decontaminating instruments prior to placing
them into the autoclave. Indicate whether instruments are manually washed or machine washed,
such as with an Ultrasonic machine. Describe the material used for soaking dirty instruments in the
machine.
N/A
J. Disinfection Products: List the disinfectant products used at the body art facility.
Madacide wipes/ spray bottle
Page 5 of 7
Body Art Facility Infection Prevention and Control Plan
K. Time and Temperature: List the temperature of the autoclave and duration of time at that
temperature required for the sterilization of clean instruments. Indicate where the sterilization log is
maintained on -site.
Time:
Temperature: N/A
Psi:
L. Personal Protective Equipment: List the personal protective equipment used during a body art
procedure for the practitioner and the client.
Nitrile gloves,
disposable dental bibs over pant legs
M. Handwashing Sink: List the locations of the hand wash sinks and describe the items supplied at
each sink.
:no _1 •.Ioil '! 1 l' • l' �.
Foot pedal operated and will each have a soap dispenser and
nser.
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.
Non adherent sterile pads are administered to the clients new tattoo along with self adhesive wrap.
Client is instructed to leave the bandage on for 1-3 hours. Upon removal of the bandage it is recommended the
client wash the area with non -scented or an i ac ena soap atter which a thin layer ot aquae ore or
sun,salt water,chlorine and lakes being ever mindful to wash their hands frequently and avoid constant touching
of the area.
O. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken when
there is an accidental spill of sharps.
W
on the floor it
disinfect.
as
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.
A small trash rprpntarlp will ha at the rprpntinn arpn fnr nffirp t�tnp imp Rnth
Artist stations will have a tall 13 gallon stainless steel trash receptacle marked "biohazard "
Gloves will be placed in these receptacles.A small trash receptacle for the bathroom will alsi
be proMeTr
Page 6of7
Body Art Facility Infection Prevention and Control Plan
Q. Negative/Failed Spore Test: Describe the procedure conducted when a monthly spore test has
failed. Indicate where the facility maintains a spore test log on -site.
N/A
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.
`DYNAMIC INK" is the manufacturer of the ink used at NEW ENGLAND NOIR LLC
Distilled water is the only water used to dilute inks
S. Service Animals: Describe the facility's policy regarding service animal presence in procedure,
decontamination, and sterilization areas.
Servo .. animals shall he allowed next to the client at all times nrovoded
They are well trained and stay still, obeying their owners commands when
In procedure and sterilization areas
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 madp'Iierein W correct and true.
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 sty ments made herein are correct and true.
Signature:
Date:
Page 7 of 7
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name
0/2-�-�V&6a 1
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\ScotPs Documents\Food Establistunents- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of IndustrialAecidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: New England NOif LLC
234 N. Main st.
city/state/zip: Mansfield MA. 02048 Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑ lyfi a employer with employees (full and/
5. F1 Retail
r part -thee).*
6. ❑ Restaurant/Bar/Eating Establishment
2.
KZ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
[No workers' comp. insurance required]
3. ❑ 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 by
11. ❑ I3 Care
are a non-profit organization, staffed volunteers,
12. Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box N 1 must also fill out the section below shoving 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
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is thepo/icy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. #
Expiration Date:
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 imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DfA for insurance coverage verification.
I do hereby certify, under th fpains 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 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
Phone
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fenn Revised 5-26-05
Town of
Town of Mansfield - Board of Health 6 Park Ronwansfield
Mansfield, MA 02048
OPERATOR NAME: Albert Benjamin Thompson
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH: 1 0/28/1 979 (A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS: 168 Pleasant st. #1
CITY: Attleboro STATE: MA. zip: 20703
MAILINGADDRESS: 168 Pleasant st #1 _
CITY: Attleboro. STATE: MA. zip: 02703
PHONE NUMBER OF OPERATOR: 508-431-4832
EMAIL OF OPERATOR: Benthompsontattooer@gnlail.Co
PLACE OF EMPLOYMENT AS A PRACTITIONER: -New-En-gland Noif LLC
ADDRESS: 234 N. Main St. _
CITY: Mansfidd. STATE: MA. zip: 02703
PHONE NUMBER OF ESTABLISHMENT:
TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check al) that apply)
KTattooing ❑ Body Piercing ❑ Micropigmentation
PROJECTED DATE FOR BEGINNING OR RENEWAL: 9/01 t2021
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT:
mmmmmmx�
First Aid and CPR Certifications for tattoo and piercing
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPRIAED - Adult Certificate expires:
Preventing Disease Transmission and/or Bloodborne Pathogen Training
Bloodborne Pathogens Certificate expires:
Course work / training on human anatomy (body piercing only)
Course work / training on skin diseases, disorders and conditions for tattoo and piercing
Llepatitus 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 t e Board. �1
Signature: Date:
FEE: $100.00 _ J
bwoaDOrne Yainogem for tway ana I a1100 . M cERTIFICATF NIPABFR I
Artists s 162813428962410
I Albert Thompson k I
DATFISSDEO IIFFEWDY r� • INSTRUCTOR
04 Aug 2021 rlR Aur, 2022 ROY W. SHAW N100
THIS CARD CERDNES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE
EDUCATION IN OSHA BLOODBORNE PATHOGENS STANDARD 29 CFR 1910.1030AND aiJe of tib:alrn :II oha;ul rLJam i
BODYARTSAFETY www. rola6rin S.mm Su ml p g pp pproVolnings.com
L----------------------------------�
AtlUU (.I'WAtU tt First Altl
CerenHCATP NDIK¢BR
�}'
160895207762410
I
E
I
I Albert Thompson
"
I
RSTROCYOR
DATERENEW BY
I 250ec202 2020 25 )ec 2J22
��
ROY W.SHAW 8300 I
THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE
NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS
:r Loi<
de na rtulate
CURRICULUM AND TH E 2015 AMERICAN HEART ASSOCIATION, GUIDELINES
www,prolrainingscom
supporlC'p rolFainings.com
L---------------------------------�
Town of Mansfield
6 Park Row, Mansfield, Massachusetts 02048
Health Department
Amy Donovan -Palmer, MPH, R5, Health Agent
New Body Art Establishment Owners:
All Body Art Establishment, Practitioner and Apprenticeship Permits will expire at the end of the
year they're issued.
Body Art Establishment Permit's require the following:
1. Application for Offering Body Art Services
2. Required forms listed on the Application
3. Body Art Facility Infection Prevention and Control Plan signed by all Practitioners
practicing at the establishment.
4. Tax Certification Form
5. Worker's Compensation Insurance Affidavit: General Business is required. (Read the third
paragraph on the "Information and Instructions" sheet.)
Body Art Practitioner Permit:
1. Practitioner's Application for Offering Body Art Services
2. Copies of necessary documentation listed on Application
Body Art Apprentice Practitioner Permit:
1. Apprentice Practitioner's Application for Offering Body Art Services
2. Copies of necessary documentation listed on Application
3. The following permit fees apply to these renewals:
Permit
Fee
Body Art Establishment
$200
Body Art Practitioner
$100
Body Art Apprentice Practitioner
$75
Please contact the Health Department if I can be of any further assistance.
Sincerely,
o
Amy Donovan -Palmer, MPH,
RS Health Agent
Phone (508)261-7366 Fax (508)261-7425 Email adpolmer@mansfieldma.com
C
c '-Z b
a)
aj
� •ti
v� O
o
v �
• o *Q
1
o �
• blJ •v., �
L4