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Home My WebLink AboutJason G. Moretti 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Practitioner's Permit for Offering Tattoo or Body Piercing This is to certify than JASON G. MORETTI Permit Number: 16 IS HEREBY GRANTED A PERMIT FOR A BODYART PRACTITIONER AS Tattooing CJ Body Piercing I J Micropigmentation located at: MASTER METHOD TATTOO 116 NORTH MAIN STREET MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: i American Red Cross CPR/AED -Adult Certificate expires: 3/20/2020 Bloodborne Pathogens Certificate expires: 3/2412020 This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires onDecember 31, 2018 unless sooner suspended or revoked. MANSFIELD BOARD OF HEALTH MichaeCMcCCean, Chairman of Mansfield Town of Mansfield - Board of Health ,' ' ° Q V 0'62018 Practitioner's Applicationfor Offering Boily ArtS�__ OPERATOR NAME: vv V RC -f-1 Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH' f — f q - 3 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: M CITY: 7 1"_[_ v `-_ySTATE M t ZIP _ _ 01 770-1MAILING ADDRESS: -� oie* 6" 'M' t �ty CITY: .u/t ori a ".RNM STATE: ZIP: _ 0.-[ -?o t PHONE NUMBER OF OPERATOR: - O � -1 `66tit" S / - EMAIL OF OPERATOR: -wovAc _ A� 16(1. PLACE OF EMPLOYMENT AS A PRACTITIONER: YV,r 1,\ ��- ,� �t4"tYoc) ADDRESS:M�. /4�1pe> _. , 1044N !- -- CITY: �M ..... �y_�. / CITY' _lY�fd'fv�.�lJ__-1 _ STATE: �1 v'.U.J �..__ ZIP: _V.—Q-t.9- _.._. PHONE NU ER OF ESTABLISHMENT: t7l TYPE_ O PRACTITIONER PERMIT APPLYING FOR (Check all that apply) -- Tattooing Body Piercing J ��rrMicropigmentation 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 CPRlAED - 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 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 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,, f tii i U C ` Date: FEE: $25.00 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. Sign eof Individua�Corpo�rateName i) D" Gl()y G **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 me't,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. R.\FIealthVa e's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth of Massachusetts Department ofl'ndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 0211 4-2 01 7 lowwww.mass.govldia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Address: Phone #: f Are 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. FjRestaurant/Bar/Eating Establishment 2. 1 am a sole proprietor or partnership and have no 7, Q 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]* I l ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12, ❑ Other with no employees. [No workers' comp, insurance req.] *Any applicant that checks box #I 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 organization should check box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins, Lie. #- 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 $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify, under the pains andlpenalties ofperjuty that the information provided above is true and correct. if, ice; ' f Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone l{ i a A 1 j r� [ µ � r % w} ! .. m `� Y Aj ➢ � �... �� Town of Framingham Board of Health Room 221 Memorial Building Framingham, MA 01702-8325 Tel. (500620-4827 Fax. (508)620-4833 Application for Tattoo Artist Certificate of Registration and/or Manager of Establishment Date: I Vz Name of Applicant: Home Address: 5- fLooeu.s ' 1T .4DiAZ vtAA, G(&")( Date of Birth: 3 Telephone Number: (�%_�� 1 S 2. -hof iG Proposed Place of Practice: Address: w0 Q.cCsaT_Iz (� . Telephone Number: !U$ - N Z. -q Training: (submit the following) 1. Copy of your successful completi:m of Basic Training in First Aid and CPR, as well as re -certification. 2. Copy of your successful completion of an OSHA course in Prevention of Disease Transmission and Blood-borne Pathogens. Such knowledge shall include the requirements of the standards in CFR 1910.1030. 3. Official transcript(s) of successful completion of an Approved level Anatomy and Physiology course. 4. Proof of negative mantoux (Tb) test within 60 days previous of application. 5. A letter or certificate of successful completion of a one-year apprenticeship under the supervision of a trained, experienced, professional tattoo artist. 6. Copy of the License of the Professional Tattoo Artist under whom the apprenticeship was completed. 7. Copy of driver's license/State identification card showing evidence that the applicant is not less than 18 years of age. (over) kn U LOA ? ,I, �, a ,, `, I !!t � � �., � �� z��j t r 3 i i � a � r �} ' r � t�I �+ 1 3 L � n c� i s -. _ r, , LIE Q 0 ED _' co M L y N 'O k CL LO f0 Q m 0 0 G N_ N oo LL v N a D LL m O 4a d = Q IL E a N CL L N O N � c0 N z W L y N 'O k CL LO f0 Q m a) 0 E o0. 0 G N_ N oo N GCD 'x W E a C C N M ao li E d C r. to LL m O 4a N O VA U) s m N S 05 m o G N 0 S c6 C O m E ro City of Framingham "r Department of Public Health `�Vf Public Health Board of Health Mailing Address: 150 Concord Street, Framingham, MA 01702 Laura T. Housman, MPH - Chair Physical Address: 31 Flagg Drive, Door#14, Framingham, MA 01702 Michael R. Hugo, Esq_ - Vice Chair Office Telephone: (508) 532-5470 Tammy C. Harris, MD, MPH-Secretaryy Office Fax: (509) 532-5760 David W. Moore, MD Office Email: health(anhaminghamma.gov Judith Wester, RN, BSN, MSN Director of Public Health: Samuel S. Wong, PhD Tuesday, July 31, 2018 $50.00 In accordance with regulations promulgated under authority of Chapter 94, Section 350 A and Chapter III, Section 5 of the Massachusetts General Laws a Permit is hereby granted to: Jason Moretti Whose Place of Business is: 247 WORCESTER RD Permit For: TATTOO ARTIST Restrictions If Any: To Operate in the CITY OF FRAMINGHAM This permit expires Friday, May 31, 2019 BOH 160276 Samuel Wong PhD�� — Director of Public Health NUMBER FEE 2004-05TAT $50.00 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF FRAMINGHAM This is to Certify that Jay Moretti 247 Worcester Road, Framingham, MA 01701 IS HEREBY GRANTED A LICENSE For TATTOO ARTIST at Masterpiece Tattoo and Bodypiercing, 247 Worcester Rd, Framingham, MA 01701 This license is granted in conformity with the Statues and ordinances relating thereto, and expires 5/31/2004, unless sooner suspended or revoked. 6/4103 PUBLIC HEALTH ADMINISTRATOR 13:36 508-620-4833 FRAMINGHAM BOH PAGE 01101 NO, 2� O�Tf�T TOWN OF FRAMINGHAM DATE BOARD OF BEALTR FEB2 GENFRAL APPLICATION 'he tmdersignedherb applies �C e��cordance ndih the provisions of the Statues rclating thcretn. 4AME L `1 WDRBSS Cl HODYPIERCER ($50.00) TANNINQ FACILITY MASSAGETHERAPIST($50,00) F--] ORESTA13LISHMFN'T �I ($100.00) ❑ OR ESTABLIS,HMENT($100.00) (L00.00) ❑ TO KEEP ANIMALS MOTET, ($50.00) TATTOO ARTIST ($50.00)OR ($50.00) ESTABLISHMENT ($100.00) ADDITIONAL MOP"MATTON; APPROVED BY Signature of Alrp a _ DAT13APPROVED TetepboneNumber; NUMBER 2003-7TAT THE COMMONWEALTH OF MASSACHUSETTS TOWN OF FRAMINGHAM rhis is to Certify that Jason Moretti 85 Rogers Road, Apt. 2, Lowell, MA 01851 IS HEREBY GRANTED A LICENSE For TATTOO ARTIST at Masterpiece Tattoo and Bodypiercing, 247 Worcester Rd, Framingham, MA 01701 FEE $35.00ek This license is granted in conformity with the Statues and ordinances relating thereto, and expires i/31/2003, unless sooner suspended or revoked. ao -T—. PUBLIC HEALTH ADMINISTRATOR NUMBER FEE 2005-04 TAT $50.00 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF FRAMINGHAM This is to Certify that Jason Moretti 247 Worcester Road, Framingham, MA 01701 IS HEREBY GRANTED A LICENSE For TATTOO ARTIST at Masterpiece Tattoo and Bodypiercing, 247 Worcester Rd, Framingham, MA 01701 is license is granted in con ormi y with the titatues and ordinances relating triereto, an expires 5/31/2005, unless sooner suspended or revoked. A"- -_ CV, 5/20/04 PUBLIC HEALTH ADMINISTRATOR f. Wilfredo "Torres of *E2st l:"oast.'rattoo, attest by my si anature Esefow khat' I apprenticed Jason Moretti in the art of tattooing. Jason's' apprenticeship began approximatel_y_March___ hR .TC,i,_ of 7092 uStuiuiZation procedures, cross contamination, m traction in bloodbo�mie pefficgens,`-pis v✓eij Las. tattoo tCbiuut.1i3CS.H1i.0 .a.i ter e3iC. I* fi-WZ4---� `Sa ijfrado l'orres Mastc iv ce Robert T. Cooper Framingham Board of Health Memorial Bldg., Rm. 221 Framingham, MA 01701 Dear Mr. Cooper; Susan F, Carroll Masterpiece Tattoo 314B S. Broadway Salem, NH 03079 At this time we have two artists we wish to license for our Framingham location. We request that Daniel Paine be placed on the agenda for the October meeting. We request that Jason Moretti be placed on the agenda for the meeting to be held in November. Both of these artists came to Masterpiece having been trained in tattooing at other studios. Jason Moretti had been tattooing previously at East Coast Ink, located in Pelhani, NH. Jason had been tattooing there for approximately ten months prior to starting at Masterpiece. He then tattooed under the direction of Dan Carroll for a period of two months, to ensure both competency as well as conformity with our standards. Daniel Paine has been tattooing for approximately ten years. Most of this time was spent underground prior to legalization in MA. At that time he began tattooing at Tribal Ways, located in Boston, MA for a period of eleven months, then at Miraculous creations, located in Worcester, MA, until joining Masterpiece in September of this year. Both his tattooing skills, as well as his practices and procedures have been monitored closely to ensure competency. At this time we are comfortable with the knowledge and procedures practiced by both. Masterpiece has provided training in Anatomy/Physiology, CPR/First Aid, as well as Bloodbome Pathogens. Enclosed is all the documents needed for Daniel Paine. I will forward all information on Jason Moretti in sufficient time for the Boards' review prior to the November meeting. Thank you once again for your help in this matter. If you have any further questions, please do not hesitate to contact me. Sincerely Susan F. Carroll 9 ; 01 CD WD N 0 9 iii I um OC P n PIZ01 ® ® CD Cif N �11 VV 11 l L QM raP iaf ISI � 9 iii I W E t7 w CD Q a.Q CD ra VA 05/11/2004 13:11 50B-620-4833 FRAMINGHAM BOH PAGE 01/01 NO. ®� TOWN OF FRAMINGHAM DATE BOARD OF REALTIA FEE GF,NEItAL APPLICATION The .mdersi nod hereby applics for a L.iccnse in accordance with the provisions of the Siames relating thereto. ADDRESSE2yI BODYPIERCER ($50.00) TANNING FACILITY M SSA.0 E TjiERAPIST (350.00) ❑ OR ESTABLISHMENT ❑ ( $100.00) ❑ OR BS /\.BLISHMFNT ($100.00) (1.00.00) ❑TO KEEP ANIMALS F MOTEL ($5Q.00) ZITATIOO ARTIST ($50,00)OR ($50,00) 2STA13I,SSHMP.DIT ($100.00) ADDITIONAL INFO,RAATION' APPROVFD BY Signal ue of Applicant DATE APPROVED__ TelcphoacNnmber- Town of Framingham Board of Health Room 221 Memorial Building Framingham, MA 01702-8325 Tel. (508)620-4827 Fax. (508)620-4833 Application for Tattoo Artist Certificate of Registration and/or Manager of Establishment Date:oz NameofApplicant: �CuN V�IC (Z.v 7 I I Home Address: Y_ QCT):C-2S S( APT Z (oW_--cL MA Date of Birth: / /N11 \3 3 Telephone Number. 09,q 1 2 -r CYC` Co Proposed Place of Practice: Address: �.c+� �v02ct-_STI-V �__ RD Telephone Number: S -C) � - n 5 -2 N Z.cj Training: (submit the following) 7 TAT Copy of your successful completi :n of Basic Training in First Aid and CPR, as well as re -certification. 2. Copy of your successful completion of an OSHA course in Prevention of Disease Transmission and Blood-borne Pathogens. Such knowledge shall include the requirements of the standards in CFR 1910.1030. 3. Official transcript(s) of successful completion of an Approved level Anatomy and Physiology course. 4. Proof of negative mantoux (Tb) test within 60 days previous of application. 5. A letter or certificate of successful completion of a one-year apprenticeship under the supervision of a trained, experienced, professional tattoo artist. Copy of the License of the Profe sional Tattoo Artist under whom the apprenticeship was completed. 7. Copy of driver's license/State identification card showing evidence that the applicant is not less than 18 years of age. (over) 11/9/2018 To Whom It May Concern, I decline the Hepatitis C Vaccine. Regards, Jason Moretti MJ 0 00 �i Cl 00w 0 U � C�o - I Ar H _0 TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TOTREASURER — DBaRmeOf: BOARD OF HEALTH TATOOPPACIITIONER'SLICENSE� I Date: 111/15201$ 25.00 25.00 Or Bank N PktN The above is a detailed list of moneys collected by me, amounting in the aggregate to: 8 zs co Ifor the period ending 111/152011 _ which I have paid to the Town Treasurer whose receipt I hold therefor. I —�