HomeMy WebLinkAboutAaron T. Rampello 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 that:
AARON T. RAMPELLO
Permit Number: 9
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing [ _I Body Piercing Irl Both
located at.
MASTER'S METHOD TATTOO
116 NORTH MAIN STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires:
American Red Cross CPR/AED - Adult Certificate expires: 4/23/2018
Bloodborne Pathogens Certificate expires: 3/1112018
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
.MichaeC.McCCean, Chairman
Town of
Town of Mansfield - Board of Health 6 Pak Rowansfield
Mansfield, MA 02048
Practitioner's Application for Offering Tattoo or Body Piercing Services
OPERATOR NAME: AARON T. RAMPELLO
Please attach recent identification photograph here (with head and shoulders, front view,),approximately_,W inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH: 12126/1973 D C 0 'i," ° r
(A practitioner shall be a minimum of 18 years of age.)
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: (508) 654-6024
EMAIL OF OPERATOR: AARONR.MMT@GMAIL.COM MASTERSMETHODTATTOO@GMAIL.
PLACE OF EMPLOYMENT AS A PRACTITIONER: MASTER'S METHOD TATTOO
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
it Both
PROJECTED DATE FOR BEGINNING OR RENEWAL: 12/31/2017
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?
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: 4/23/2018
Bloodborne Pathogens Certificate expires: 4/19/2017
Please describe your procedures to assure that individuals under eighteen
years of age will not be served without proper consent:
moire a poreo_ car g�nvckbn C6l-c) � o�ci _ bnvD cWck 64 cer*
When shaving of a site or area is necessary, will you use:
Disposable razors Iveyes i No
Non-disposa zors Yes No
Other:
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: G""
AAAA
Page 2 of 2
Date: _r_430[)-7
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or C rporate Name
""Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, iitApplicable)
*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.
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