HomeMy WebLinkAboutPatrick Tierney 12/31/2018Amy Donovan -Palmer
From: Jaime Carleton <jaimec.mmt@gmail.com>
Sent: Friday, April 06, 2018 2:19 PM
To: Amy Donovan -Palmer
Subject: Tattoo Artist
Hey Amy,
Long time no talk! Hope things are going well with you.
I wanted to let you know that as of today, Patrick Tierney is no longer an artist here at Master's Method Tattoo,
Inc.
We had some issues with him recently and can no longer allow him a chair in our shop.
Hope you have a great weekend.
Thanks,
Jaime
774-719-2821
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Practitioner's Permit for Offering Tattoo or Body Piercing
This is to certify that:
PATRICK TIERNEY
Permit Number.' 12
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing Body Piercing Cl Both
located at.,
MASTER'S METHOD TATTOO, INC.
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires: '..
American Red Cross CPR/AED - Adult Certificate expires: 8/18/2019
Bloodborne Pathogens Certificate expires: 7/25/2018
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
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Practitioner's Application for Offering Tattoo or Body Piercing Services
OPERATOR NAME: PATRICK TIERNEY
Please attach recent identification photograph here (with head and shoulders, front view,) approxitpat9ly 2x3 riches .
in size. Clear photocopies are acceptable.
DATE OF BIRTH: 7114/1992
(A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS: 72 FRANKFORT STREET
STATE: MA zIP: 02128
CITY: BOSTON
MAILING ADDRESS: 72 FRANKFORT STREET
CITY: BOSTON STATE: MA ZIP: 02128
PHONE NUMBER OF OPERATOR: (508) 292-7692
EMAIL OF OPERATOR: /9.t r/Gk 7o /1nm7 (f /rdv1. am
PLACE OF EMPLOYMENT AS Ai PRACTITIONER: MASTER'S METHOD TATTOO, INC.
ADDRESS: 116 NORTH MAIN STREET
CITY: MANSFIELD STATE: MA Zip: 02048
PHONE NUMBER OF ESTABLISHMENT: (774) 719-2821
TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply)
Tattooing
Body Piercing
Both
PROJECTED DATE FOR BEGINNING OR RENEWAL __ �pHl •[ r{2fJ/(�
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT:
FEE: $25.00
Page 1 of 2
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Practitioner's Application for Offering Tattoo or Body Piercing Services
(continued)
PLEASE INITIAL YOUR RESPONSES
Procedures must be maintained and documented that ensure all persons performing body piercing or tattooing
services on the business premises have received appropriate training.
Please attach copies of certifications. Initials
First Aid and CPR Certifications for tattoo and piercing? /7 -
Preventing transmission of infectious diseases for tattoo and piercing? &
Course work / training on human anatomy (body piercing only)?
Course work /training on skin diseases, disorders and conditions for tattoo and piercing?
Universal precautions against bloodborne pathogens for tattoo and piercing?
Appropriate tattoo and body piercing after-care for tattoo and piercing? _
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPR/AED - Adult Certificate expires: 8/18/2019
Bloodborne Pathogens Certificate expires: 7/25/2018
Please describe your procedures to assure that individuals under eighteen
years of
age will not be servedwithoutproper consent: 1
/mN M/Yr-O%� d% �ayfiLl//�/1/Ae y(.GLflG�lri%l O�Ga- `Yl//9/%� CGNl10/ y/dG (.pnS� fD1' �IGh'i ap �jE 'fz-if°°'�.
/1/,DEI�/oh u,�tlW u�. htect� cam./ hel �n-tfoo°f . ✓
When shaving of a site or area is necessary, will you use:
Disposable razors
Non -disposable razors
v1Yes !_l No
Yes C1 No
Other: oyes, aelxl/ y lw S-ar A'lw /e� '-f ///I/-A&I' yW 4,vd
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: /�
Page 2 of 2
Date:
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 Incliviclud or Corporate Name
**Social Security No. (Voluntan) 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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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