HomeMy WebLinkAboutFrances Flores @ NE Noir - 12/31/2021"!r)20
of Mansfield
Town of Mansfield - Board of HRow
ield, Ma ozoas
Practitioner's Application for Offering Body
OPERATOR NAME: `Ri�,K,i S
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are cceptable.
DATE OF BIRTH: n 6q (A practitioner shall be a minimum of IS years of age.)
RESIDENCE ADDRESS: IJ V-A -�H '57uQ
CITY:,:..r�%.Ui STATE v^�".i< ZIP: t 'a' ;/.�`"
MAILING ADDRESS: E' 14 N. /VAAlM ' S'f.
CITY: P^O!'PST1� ,L.D _...._. STATE: /VV? ZIP: cv, t
PHONE NUMBER OF OPERATOR:
EMAIL OF OPERATOR: t"n,.w ,, ast-i... -.a:a,,,._
PLACE OF EMPLOYMENT AS A PRACTITIONER: N
ADDRESS:
N) ,
CITY: ......._. l' _Iyr�,$ �- d t-t,:l ._.STATE: Me ZIP: - [?Z �� -("
PHONE NUMBER OF ESTABLISHMENT:
TYPE QF PRACTITIONER PERMIT APPLYING FOR (Check at; that apply)
Tattooing ❑ Body Piercing ❑ Mi ropigmentation
PROJECTED DATE FOR BEGINNING OR RENEWAL: L I 'Z _c1,'_$
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT:
Please attach copies of appropriate documentation
First Aid and CPR Certifications for tattoo and piercing
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPRtAED - Adult Certificate expires:
Preventing Disease Transmission and/or Bfoodborne 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 `r"'ith the provisions of the Town of Mansfield Board of Health Regulations for
Body Art Establishm ht$ made under the authority of M.G.L. c.111 § 31.
Practitioner permits si all be v4d ifrom the date of issuance and shall expire on the last day of the year of issuance
unless revoked soon r y the Board.
Signature: Date:
FEE: $100.00.�° — ......
u
Town of Mansfield
Town of Mansfield - Board of,I' ealth 6 Park Row
Mansfield, MA 02048
Apprentice Practitioner's
OPERATOR NAME:
Please attach recent identification photogr
in size. Clear photocopies are acceptable.
DATE OF BIRTH:
RESIDENCE ADDRESS:
CITY:
MAILING ADDRESS: _
CITY:
PHONE NUMBER
EMAIL OF OPERA
PLACE OF EMPLC
ADDRESS:
CITY:
PHONE NUMBER OF ESTABLtSHN
TYPE OF PRACTITIONER PER( 11
El Tattooing `l
PROJECTED DATE FOR BEGINO
IF A TIME LIMITED EVENT, NAME
OPERATOR:
AS A PRACTITIONER:
for Offering Body Art Services
(with head and shoulders, front view,) approximately 2x3 inches
(A practitioner shall be a minimum of 18 years of age.)
STATE: ZIP:
STATE: ZIP:
TE: . ZIP:
APPLYING FOR: (Check, a0 that apply)
Body Piercing ❑ I
G OR RENEWAL:
kND 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 Ft rat Aid Certificate expires:
American Red Cross CPR/AED -Adult Certificate expires:
Preventing Disease Transmission and/or Bloodbonie Pathogen Training
Bloodborne Pathogens Certificate empires:
Course work /training on human anatorny (body piercing only)
Course work/training of) skin diseases, disorders and conditions for tattoo and piercing
Hepatitis B vaccination status or Declination Notification Letter
Signed and notarized agreement with a permitted Body Art Practitioner
Applicant Statement of Consent: I have recieved and read a copy of the Town ofMansfield 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 pemrits shall be valid from the date of issuance and shall expire on the last day of the year of issuance
unless revoked sooner by the Board.
Signature: _ Date:
FEE: $75,00
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under la'W.
Signature �f Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Niunber
*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:\Clsers�sleile,,Da ktop\Scolrs Doeumenls\EoW EsinbIishmellls-"Pomp\TAX CERTIP[C,\'rION GORM.doe
Body Art Facility Infection Prevention and Control Plan
Q. Negative/Failed Spore Test: Describe the procedure conducted when a monthly spore test has
failed. Indicate where the facility maintains a spore test log on -site.
R. Commercial Ink or Pigment Manufacturers: List the m
used at the facility. Describe the procedure for dilution of in
dilution of inks or oiaments. ._
S. Service Animals: -Describe the facility's
decontamination; `and sterilization areas.
Maintain a copy of this
Health.
I hereby certify that
or individuals invol,
the procedures ant
belief, the statemen
Signature:
For Body Art Practitione
with the procedures
knowledge and belief,
Signature:
Signature:
pleted document i
herein are
at the
regarding
your files.
made
s performing t
n and steriliza
in this docurr
ct and true.
nent: /
ad in
are co,
Date:
Date:
'er(s) 'for, the inks or pigments
sterile water should be used for
i
1
service animal presence in procedure,
t one copy to the Mansfield Board of
dy art at this facility and employees
an procedures have been trained with
nt. To the best of my knowledge and
;'feby certify that I have been trained
is document. To the best of my
c`t and true.
1
L,
d
a
y
Page 7 of 7
Town of Mansfield - Board Of Health
Tattoo License Application
1, Francis Flores, decline the Hepatitis B vaccine, due to religious exemption.
Thank you,
Francis Flores
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