HomeMy WebLinkAboutRectify Barbershop & Beauty Alcove, Inc. 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit for Offering Tattoo or Body Piercing
Permit Number: 4
This is to Certify that:
RECTIFY BARBERSHOP & BEAUTY ALCOVE, LLC
90 COPELAND DRIVE
MANSFIELD MA 02048
IS HEREBY GRANTED A PERMIT
FOR A BODYART ESTABLISHMENT
(TATTOO, PIERCING, AND
MICROPIGMENTATION)
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires on December 31, 2018 unless sooner suspended or revoked.
MANSFIELD BOARD OF HEALTH
Michae[McCCean, Chairman
Town of Mansfield - Board of Health
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Town of Mansfield
6 Park Row
Mansfield, MA_02Q48
Application for Offering Body Art Services
ESTABLISHMENT NAME: f
ADDRESS: Qr, Nryr I
CITY: VpAn!g�2.Id
PHONE NUMBER OF OPERAT
NAME OF OWNER Sha.
ADDRESS:
CITY:
PHONE NUMBER OF OWNER:
EMAIL OF OWNER:
STATE: PIPE-_ ZIP: O -L
STATE: AA— ZIP: o 5
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
CCi ea-j-
`14
MAILING ADDRESS FOR APPROVAL NOTIFICATION ANrRENEWAL: V
''10� nC -be: tt%c manS:��I A oa�
TOTAL SIZE OF OPERATION IS: ®® rj FT.
PROJECTED DATE FOR BEGINNING OPERATION: �Sc 01- I FAIR OR IF RENEWAL, RENEWAL DATE
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT
Additional forms to be submitted:
, Cltenl Application
%informed Consent Form
Drawing of the floor plan
%Injury and/or Complication Report (blank)
Mfisclosure Statement
7osure Incident Report (blank form)
on Prevention and ControU 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,) 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.
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S gnature of establishment owner PFA name of establishment owner
FEE: $160.00
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
,L, ". -
Signature 9f Individual or Corporate Name
da` 1C1a
**Social Security No. (Voluntanj) or Federal
Identification Number
By: Corporate Officer (Mandatonj, 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\Scotfs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth ofMassaehusetts
Department oflndustrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Amlicant Information Please Print Legibly
Business/Organization
Address:
City/State/Zip:
Are y9u an employer? Check the appropriate box:
L I am a employer with employees (full and/
or part-time).* hoyxt 0..i-okiciAmt
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.]
M
Phone #:
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
S. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I LEI Health Care _
Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy' onnation.
**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 the policy information.
Insurance Company Name: e jP eJS ( p dt,'� bAal r In u 1 A Ic, a tal.11 u l t r
Insurer's
City/State/Zip: Vnfh!6� , N� 145Q0
Policy # or Self -ins. Lie. #_ u [� — Q6�� 51 �� (y� Expiration Date: 3101 I aiD I'
�_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and,eex-`p`i`ration 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 DIA for insurance coverage verifirnflnn
I do hereby
under the pains and penalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in tills 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
www.mass.gov/dia
Phone
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TRAVELER976k
ONE TOWER SQUARE
HARTFORD CT 06103
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: DB-2L512269-18-42-G
NEW-18
INSURER: TRAVELERS CASUALTY AND SURETY COMPANY
1.
INSURED:
NCCI CO CODE: 11223
RECTIFY BARBERSHOP & BEAUTY PRODUCER:
ALCOVE PAYCHEX INS AGENCY INC
90 COPELAND DR 150 SAWGRASS DR
MANSFIELD, MA 02048 ROCHESTER, NY 14620
Insured is A LIMITED LIABILITY COMPANY
Other workplaces and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 09-oi-is to o9-.01.-.1912:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the states) listed here:
MA
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;
Bodily Injury by Accident: $ 500,000 Each Accident
Bodily Injury by Disease: $ 500,000 Policy Limit
Bodily Injury by Disease: $ 500,000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OR OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules. Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY
DATEOFISSUE: 09-07-18 JW
385 OFFICE: PAYROLL 70A
PRODUCER: PAYCHEX INS AGENCY INC SV996
005388
e.
please read and check all lines
❑ 1 am 18 or older
❑ Aftercare instructions have been explained to me and a copy has been given to me.1 will
follow the aftercare to the best of my ability. I will call my artist if I have any questions
regarding healing.
0 [understand that a certain amount of discomfort is associated with this procedure and
that swelling, redness and bruising may occur.
❑ 1 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
❑ 1 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.
❑ 1 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.
❑ 1 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.
❑ 1 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.
ClientSignature Date
Artist Signature Date
Client Medical History Form
02018 Rectify Barbershop & Beauty Alcove, LLC
Mansfield
Body Art Establishment
Inspection Form
Name of Establishment: _
Address ofEstablishment:
C) C ,x� -- Tel.#1 )
Establi"ment Owners) Name(s):
Owner(s) Address'.
Inspector Name:
Inspection Date:
Time:
Begin: —am � prr)
End: —am —pm
Type of Establishment:
— Tattoo —
Piercing — Tattoo and Piercing Micropigmentation
Reason for Inspection:
Pre -Operative
Inspection — Annual Inspection
— Complaint Investigation — Injury Report Investigation
Key:
Violation column:
Viol Corrected column:
Reinspection Date:
Inspector
"X" indicates a violation of the Body Art Regulations
"✓ " indicates compliance with the Body Art Regulations
"✓ " indicates compliance with the Body Art Regulations upon reinspection of the
violation.
Date when violation was noted as being in compliance with Body Art Regulations.
Viol Reinsp
REGULATION VIOLATION COMMENTS Corrected Date
Physical Facility- Overall:
(cont'd)
Client waiting area
-separate from body art procedure areas
No animals except:
- service animals
-fish aquariums in non -procedural areas
Free of insect and/or rodent infestation
VI/
Adequate ventilation
Adequate lighting
—20 foot candles 3 feet off floor
VX
Toilet room (1 at minimum):
-toilet
-sink with hot/cold water under pressure
-toilet paper, liquid soap, paper towels
in fixed dispensers
-waste receptacle: covered, foot
operated.
Solid waste:
-stored in covered, leak -proof, rodent
resistant containers
-removed weekly at minimum
Janitorial sink
-adequate size
-hot/cold water under pressure
Instrument cleaning area present:
-autoclave area at least 36 inches from
c'
ultrasonic cleaning unit
Instrument storage area
-clean, dry, covered containers
V,
-secure area; instruments only
Physical Facility- Procedure
Area:
Procedure surfaces smooth, easy to clean
f
and sanitize
/
Client chairs/benches, easy to clean and
j
sanitize
i
45 s . feet per practitioner
Viol Reinsp
REGULATION VIOLATION COMMENTS Corrected Date
Sanitation and Sterilization
cont'd:
Sterilizer packs intact, no breach
a c
Disposable medical gloves available
Practitioners wear gloves for handling
instruments
Standards of Practice:
(review with Practitioner(s))
Practitioners perform body art procedures
according to CDC Universal Precautions.
Practitioners:
-maintain personal cleanliness, wear
clean clothes.
-are free of skin rash or infection
Practitioners refuse service:
- clients under the influence
- tattooing, branding, scarification of
f
clients under 18 yrs.
Ear piercing systems used on ear lobe
only,
Practitioners wash hands with hot water
and soap prior to glove application/
procedure.
Practitioners wear single -use gloves during
procedure:
-gloves changed when tom or
contaminated
Instruments contaminated during
procedure are replaced immediately
Client skin preparation:
-free of visible infection
-cleaned
Lf
Practitioners use inks, dyes, pigments,
needles, all other equipment:
-manufactured for body art procedures
only
-according to manufacturer's instructions
Aftercare instructions provided to client
Additional comments: NA