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Home My WebLink AboutMaster's Method Tattoo, 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.' 3 This is to Certify that: MASTER'S METHOD TATTOO, INC. 116 NORTH MAIN STREET MANSFIELD MA 02048 IS HEREBY GRANTED A PERMIT FOR A BODY ART ESTABLISHMENT (TATTOO AND PIERCING) 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 MichaeCMcCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Offering Tattooing or Body Piercing Services ESTABLISHMENT NAME: MASTER'S METHOD TATTOO, INC. ADDRESS: 116 NORTH MAIN STREET CITY: MANSFIELD STATE: MA ZIP: 02048 ` a. PHONE NUMBER OF OPERATION:'`-)` �( NAME OF OWNER AARON RAMPELLO -" ADDRESS: 54COLBURN STREET _ CITY: NORTH ATTLEBORO STATE: MA ZIP: 02060 PHONE NUMBER OF OWNER: C (508) 654-6024 BUSINESS (774) EMAIL OF OWNER: AARON R.MMT@GMAIL.COM 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: i AARON RAMPELLO 54 COLBURN STREET, NORTH ATTLEBORO, MA 02760 PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED WITHOUT PROPER CONSENT IDENTIFICATION/LICENSE ARE CHECKED. IF UNDER 18 PARENTAL CONSENT IS REQUIRED ALONG WITH BIRTH CERTIFICATE, PARENT'S ID & SIGNATURE MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: 54 COLBURN STREET, NORTH ATTLEBORO, MA 02760 TOTAL SIZE OF OPERATION IS: 750' FT. PROJECTED DATE FOR BEGINNING OPERATION: JULY 15, 2016 OR IF RENEWAL PUT DATE HERE: IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: i.RETEST TO RULE OUT FAULTY STRIP. IF 2ND TEST COMES BACK POSITIVE, REPAIR OR REPLACE UNIT. See app. DATE OF EVENT 12/31/2017 Bloodborne pathogens must be renewed every year. American Red Cross CPR/AED - Adult must be renewed every year. American Red Cross Standard First Aid certificate must be renewed every 3 years. FEE: $150.00 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PLEASE INITIAL YOUR RESPONSES Will procedures be maintained and documented that ensure all persons performing body piercing or tattooing services on the business premises have received appropriate training: Tattooing or body piercing? 11".j yes I ] no First Aid? u/Yes no Preventing transmission of infectious diseases? 1✓1 yes I I no Universal precautions against bloodborne pathogens? eyes I:_.I no Appropriate tattoo and body piercing after -care? \/yes L I no Will written records of equipment utilized by the business be maintained? [Aes j j no Will procedures be maintained that ensure that all non -disposable equipment, parts of [Vyes ❑ no equipment or instruments used in performing procedures are disinfected and sterilized in accordance with the Code? Will weekly biological monitoring tests of the business's heat sterilization devices be ;_Yes r�— (-] no t'r' (6n Y 1 completed? Will a record of all tests performed on the heal sterilization devices be maintained for _.I es 'j. _-_j no at least two years? Please describe your procedures for remedial action to assure compliance with the sterilization requirements in the event a test '.. indicates a heat sterilization device is not functioning properly: l� clev i c e t S htCl h (YIYI (yrp�kit ,1,,ar- s4- rd LZA V\ 09-�AWI \Mh\ U)e 1O-� fizz oan V 1d c a1. \ r 1 SEec t i z i \5 11 t naYL% And all hand sinks equ pped with. Liquid or granular soap? yes _ no Hand drying facilities? [,yes �..'; no Waste receptacles? j�yps /Yes ' y no Hot and cold water? ✓✓✓I _ j no Are there any overhead or otherwise exposed sewerage lines so as to create a [] yes [._✓no potential hazard to the sanitary environment of the business? Will sufficient and appropriate receptacles be provided for the disposal of refuse and 'ies [_j no single -use instruments? Will all waste items including but not limited to needles, razors and other supplies /yes no capable of causing lacerations or punctures be disposed of in accordance with the applicable standards of Chapter 3745-27 of the Administrative Code? Will indoor and outdoor refuse containers have lids? %/yes I,.. 1 no Page 1 of 3 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Is your water provided by a public authority If a private well, attach EPA approval. Is the building connected to a municipal sewer private well f r] private sewage disposal system If a private system, attach EPA approval. Will all plumbing work be done under permit from a plumbing authority? Will a mop sink be provided for the disposal of mop water? Will a mop sink be located out of the tattooing and body piercing area? Will procedures be maintained that ensure the general health and safety of all individuals employed by the business? Will a permanent record be maintained that includes the dye colors, lot number or other identifier of each pigment used for each tattoo? Each area in which tattooing or body piercing is conducted will have an area of how many square feet? Will all areas used for performing services be separated from each other and from waiting customers or observers by a panel or a door? Is at least 40-foot-candles of light being provided at all areas where tattooing or body piercing services are performed? /yes Wyes Fveyes ['yes Ll no no no no !V, yes I:- I no [yes ❑ no ryes ❑ no Is at least 20-foot-candles of light provided at all other areas? i /es no Describe the floor finish material directly under equipment used for tattooing or body piercing services: Will all tables and other equipment be conslry d of easily cleanable material with a ryes no smooth washable finish? _.. -__. -..-.. Will toilet room facilities be available to the employees and customers of the business? %Xes �] no Are all toilet rooms equipped with: Toilet tissue dispensers? I Aes ❑ no A mechanical exhaust fan or screened, openable window? L;4es ❑ no Self -closing room doors? Etj"yes L no Is there a hand sink in each toilet room and tattoo and body piercing area? 'I yes no Number of sinks Page 2 of 3 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Is the potable water supply protected from cross -contamination? �Vyes [. 1 no Describe the storage facilities for employees personal belongings (i.e. coats, boots, purses, etc.) ',, n `avA i�ft t�Lcva c v S �r2 �Q(* n4�\e ic -_ c�cie;�-c Will live animals be excluded from the area used for tattoo or body piercing procedures? ',,yes j no Will a separate area be provided where employees and patrons may smoke or >yes ;_] no consume food or beverages? Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: WO rx1U vie PO _TQ F __�'or_ r-%, C�r�S�c��- � l`�_._o�d�c_� �es►� �ca_�__C��I�IC�S l�� ceF-�- Will disposable latex gloves be available and changed accordingly? [V"`yes ❑ no When shaving of a site or area is necessary, will you use: Disposal razors ✓ or Non -Disposable razors Please describe how sterilized instruments and equipment will be stored. ev-CA t Zt!%JD ap (P P -i" _Cyr , _skred -N v')_ 44e6 �Q Gyp c34'e- W ill an ultrasonic type device be used to clean and disinfect non -disposal needles and [es ',__� no instruments?� - -- Will a steam sterilizer (autoclave) be used to sterilize all non -disposal needles and ✓yes no instruments? _. If no, please describe how this will be done. Please describe how you will monitor and document the sterilizer function. Vie vim._ Cr)G At4-_V'�3W�1YeA `�� `- �_ E!% vfe Signature Date: J Page 3 of 3 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. of Individual or Corporate Name By: Corporate Officer (Mangy, if Applicable) ,� I - Ho- Cw.l ( "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. R:\Aeatth\fine's Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents :a I Congress Street, Suite 100 Boston, MA 02114-2017 o= www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Business Address: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2. ❑ lam a sole proprietor or partnership and have no employees working for me in any capacity. ,�,/rNo workers' comp. insurance required] 3. Lid' 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.] Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1l.❑Vealth Care 1z,Llother —rl'Oob TIC�(C' *Any applicant that checks box #1 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 #1. 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cgttfy, under thepains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this 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 Phone