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HomeMy WebLinkAboutJaime Carleton 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Perm f _ ff g Practitioner's Permit or Offering Tattoo or Body Piercing This is to certify that JAIME CARLETON Permit Number. 11 IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS located at 1 1 Tattooing 1%11 Body Piercing I _; Both 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: 4/9/2019 Bloodborne Pathogens Certificate expires: 8/10/2018 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: JAIME CARLETON Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: 6/1311982 - '•' g (t1 (A practitioner shall be a minimum of 18 years of age.) "9 RESIDENCE ADDRESS: 54 COLBURN STREET - CITY: NORTH ATTLEBORO STATE: MA ZIP: 02760 MAILING ADDRESS: 54 COLBURN STREET CITY: NORTH ATTLEBORO STATE: MA zip: 02760 PHONE NUMBER OF OPERATOR: (978) 763-5594 EMAIL OF OPERATOR: ' carr e c . c,r rY,+__C.- V_ �_ - o r(� --- - PLACE OF EMPLOYMENT AS A PRACTITIONER: MASTER'S METROD 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 Y�lBody Piercing Both PROJECTED DATE FOR BEGINNING OR RENEWAL: \aI 2, 1 IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: J 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 most 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? Preventing transmission of infectious diseases for tattoo and piercing? Course work / training on human anatomy (body piercing only) ?G Course work / training on skin diseases, disorders and conditions for tattoo and piercing? <C 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: 4/9/2019 Bloodborne Pathogens Certificate expires: 8/10/2018 Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: (— (�D Q-0iWe � �ay1m4 ©r JuoYC i0m When shaving of a site or area is necessary, will you use: Disposable razors Non -disposable razors Other. V,)(es No Yes No 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: _ Date: k2 Jot✓ I v) _ Page 2 of 2 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. S Signature of Individual or Corporate Name By: Corporate Officer (Mandator, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Certificate of Completion Jaime Carleton has successfully completed requirements for Adult and Pediatric First Aid/CPR/AED - Valid 2 Years conducted by American Red Cross Date Completed: Sun Apr 09 2017 Instructors: Jay Atkins CeriHicate ID: OZRGYS To verify, scan code or visit: httpsz(lwww.redcross.org/on/domandware.store/Sites-RedCross-Site/default/Certificates- ViewAndPrint?certnumber=OZRGYS&selectedCerts=id-OZ RGYS Certificate of Completion Jaime Carleton has successfully completed requirements for Bloodborne Pathogens Training - Valid 1 Year conducted by American Red Cross Date Completed: Thu Aug 10 2017 lA-77 E ro �, The American Red Cross is authorized by IACET to offer 0.1 CEUs for this course. Contact Hours: 1.0 Certificate ID;10HYEB To verify, scan code or visit: htips://www.redcross.org/on/demandware.store/Sites-RedCross-Site/detauiVCerigicates- V iewAndPrinticerinumber=t OHYE8&selectedCerts=id-10HYEB