HomeMy WebLinkAboutShawn Mullin 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
Permit Number: 13
This is to certify that.
SHAWN MULLIN
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
Tattooing ❑ Body Piercing Both
located at
ART & SOUL TATTOO
88 COPELAND DRIVE
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires: 121312018
American Red Cross CPR/AED - Adult Certificate expires: 121312018
i Bloodborne Pathogens Certificate expires: 1213/2016
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
NichaeCMcCCean, Chairman
Town of Mansfield - Bow-d of Health
f ,
Town of Man§field
6 MParkpp�� QQw
jansif*1fl, MA 02040
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Practitioner's Application for Offering Tattoo or Body Piercing Services
OPERATOR NAME: ,5
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH: I 1 I [T�L
(A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS:
CITY: �i(`� STATE:ZIP:'ln
MAILING ADDRESS:
CHirN
STATE: ZIP:
PHONE NUMBER OF OPERATOR: '7744- qrJ, I5LI
EMAIL OF OPERATOR:
PLACE OF EMPLOYMENT AS A P
ADDRESS:
—___`lT /'� _.._.. -
CITY: 1�1IY _. STATE: MA ZIP: oa rV�
C� /1C! 'Z....
PHONE NUMBER OF ESTABLISHMENT: _, 00 I
TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply)
XQ Tattooing
0 Body Piercing
E] Both
PROJECTED DATE FOR BEGINNING OR RENEWAL: 1. /�-�
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT: Gp
�0
FEE: $25.00
Page 1 of 2
Town of Mansfield
Town ofMansfLeld - Board ofHealtl2 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 a// persons performing body piercing or tattooing
services on the business premises have received appropriate training.
Please attach copies of certifications.
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:...
j Bloodoorne Pathogens Certificate expires:
Please describe your procedures to assure that individuals under eighteen
years of age will not be served without proper consent:
When shaving of a site or area is necessary, will you use:
Disposable razors
Non -disposable razors
Other
h(j Yes No
Yes %t No
S�
5 VV\,
SVol',
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: (( bj/_Q
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.
A_WA,
Signature of Individual or Corporate Name
030- _6F-R59
"Social Security No. (Voluntary) or Federal
Identification Nuniber
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.
CAUsers\sleito\Desklop\Scolrs Doannents\Food Eslablishments- Temp\TAX CERTIFICATION FORM.doe
The Conunon,wealth of'Massrrchusetts
Department oflndustrial Accidents
Office of'Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name
Address:
City/State/Zip: Phone #: 5 O k" .3 3 9- -2 O O /
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
orpart-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (met. real estate, auto, etc,)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
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]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp, insurance req.] 12•® Other TftiT TO U
*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 #1.
I ant art employer that is providing worlcets' compensation insurance.for a{p eatplovees. Below is the policy information.
Insurance Company N
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration
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 D1A for insurance coverage verification.
I do hereby certify, under the pains and penalties of petjury that the information provided above is true and correct.
Offtcial 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
www.mass.gov/dia
Phone
O-CAI X1?
To whom it may concern,
I refuse to recieve the Hepatitus vaccination at this
time.
Shawn Mullin
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Jane Doucette
From: Tattoos By Anna <tattoosbyanna@hotmail.com>
Sent: Monday, November 27, 2017 2:18 PM
To: Jane Doucette
Subject: Fwd: Certificate of Insurance
Attachments: certificate.pdf
Hello Jane!
Here are the additional items requested: Workmans comp certificate (see attached) and Shawn's ID:
Thank you for your time!
Anna
Art & Soul Tattoo
88 Copeland Drive
Mansfield, MA 02048
Tues-Sat 12-9pm
By Appointment
www.artandsoultattoo.net
Begin forwarded message:
From: <OAR(a�wcribma.org>
Date: November 27, 2017 at 1:16:51 PM EST
To: <debbie(= candsins.com>, <tattoosb, anna Ahotmail.com>
Subject: Certificate
PLEASE DO NOT REPLY TO THIS EMAIL USING THE OAR MAILBOX ADDRESS.
* * WCRIBMA will not see or respond to any emails sent to the OAR mailbox. * *
.0i
m
CITY OF FALL RIVER, MASSACUSETTS
Inspectional Services Division
BOARD OF HEALTH
No. 0269
Tattooing
rae c5amrd of
to Shy
to operate at Up in
in accordance with the
the Board of Health ma
may be hereafter enact
All permits
Date Issued 12/15/2016
Date of Expiration 12/31/2017
Fee: $125.00
of Fall River, Massachusetts,
of
of the General Laws, and all
der, and all amendments the
may be revoked for cause
grants a License
St
and regulations of
now in force or that
by the Board of Health.
Signed C/A,- %fir 'fIm1111
Director of Public Health
THIS PERMIT TO BE POSTED IN A CONSPICUOUS LOCATION
CITY OF FALL RIVER, MASSACUSETTS
Inspectional Services Division
BOARD OF HEALTH
No. 0269
Tattooing Practitioner
'Me 666ard of c
to Sha
to operate at Up in
in accordance with the
the Board of Health ma
may be hereafter enact
All permits shall
Date Issued 1/1/2016
Date of Expiration 12/31/2016
Fee: $125.00
71
of Fall Riveri,Mdssah`usetts, „ere
i
of 1729 Pleasa
0
{' 3
of the General'LaWs,:'and all rules and
der, and all amendments thereto, now
and may be revoked for cause'af any time,the Bi
a License
ms of
or that
of Health.
Signedd�� %fir. sfi/!6 fit/
Director of Public Health
THIS PERMIT TO BE POSTED IN A CONSPICUOUS LOCATION
Board of Health -Art and SOUL Tattoo, LLC. - Disclosure Statement
This statement shall be given to all tattoo clients and must be signed prior to procedure.
Tattoo Disclosure Statement
Risks are associated with invasive procedures; these may include:
Pain, bleeding, swelling, infection, scarring of the area and nerve damage.
Unsterilized equipment and needles can spread infectious diseases; all equipment must be clean and sanitary before use.
Tattoos are not easily removed and in some cases may cause permanent discoloration;
carefully consider your risks when getting a tattoo.
Allergic reaction must also be considered.
The inks, dyes, pigments used for tattoos are color additives. Currently no color additives have been approved by the FDA.
Blood donations cannot be made for a year after tattoo procedures.
The practitioner should: Properly/thoroughly clean the area before procedure, use sterilized equipment/sterile techniques, provide
information for aftercare.
Health History and Informed Consent
The following conditions may increase health risks associated with receiving body ail:
Being Pregnant; Diabetes; Hemophilia (bleeding); skin diseases, lesions, skin sensitivities to soaps, disinfectants, etc.;
history of allergies, adverse reactions to pigments or other sensitivities; history of epilepsy, seizures, fainting, narcolepsy;
use of medications such as anticoagulants (i.e., Coumadin: can thin blood and interfere with blood clotting); Hepatitis or HIV
infection.
I certify with my initials the followin¢ is true:
Iam at least 18 years of age............................................................................................................
I do not have: Heart condition, Hemophilia, Epilepsy, Diabetes, Hepatitis, Narcolepsy, Seizures, or fainting spells...
I do not use: Anticoagulants, blood thinners, or any medications that interfere with clotting ........................
I am not HIV positive or under the influence of drugs or alcohol...............................................................
I do not have any mental, physical, medical impairment or disability that might affect me as a direct or
indirect result of my decision to have any tattoo related work done at this time .............................................
Please list below and tell your artist if you have any allergies (latex, shellfish, mangos etc. )
I hereby release any and all person representing Art and Soul Tattoo, LLC from any and all consequences that may be related to any
tattoo related procedures applied by Art and Soul, LLC. 1 agree for myself, heirs, assigns, and legal representation to hold harmless
from all damages, actions, and causes of action, any claim adjustments, cost of litigation, attorney fees as well as any and all costs
and/or expenses which might arise from my decision to have any tattoo procedure done by Art and Soul Tattoo, LLC.
Please print and present this form with your valid State ID or Passport:
Name: Email:
Address:
City:
Date of Birth:
Tattoo Design:
State: Zip:
License ID #:
Placement:
By signing you are stating that all information entered above is true/correct and you have read and understand all articles written
above.
Signature: X Date:
Witness: Artist:
1. Remove bandage in one hour.
2. Wash tattoo well with a mild fragrance -free soap & lukewarm water. Rinse with cold water.
3. Air dry for 10-15 minutes or gently pat dry with paper towel. No wiping.
4. Apply a small amount of a fragrance -free lotion to your tattoo until absorbed into the skin
about 3-4 times a day or as needed.
Tattoo will flake/peel like sunburn: DO NOT PICK OR SCRATCH TATTOO.
Carefully apply fragrance free lotion as needed for remainder of tattoo healing process.
DO NOT soak tattoo in shower, tub or ocean/pool or expose to direct sun or tan for 2-3 weeks.
After tattoo has fully healed, apply a high SPF to avoid sun damage.
DO NOT use other products unless directed by your artist.
If red bumps or a rash occurs you may be using too much lotion or allergic to what you are using.
If swelling and redness persist please see a physician.
The first touch-up is on us.:)
Please call or email with any questions: 508-339-2001 - Tues-Sat 12-9pm
www.ai-tandsoultattoo.net
1. Remove bandage in one hour.
2. Wash tattoo well with a mild fragrance -free soap & lukewarm water. Rinse with cold water.
3. Air dry for 10-15 minutes or gently pat dry with paper towel. No wiping.
4. Apply a small amount of a fragrance -free lotion to your tattoo until absorbed into the skin
about 3-4 times a day or as needed.
Tattoo will flake/peel like sunburn: DO NOT PICK OR SCRATCH TATTOO.
Carefully apply fragrance free lotion as needed for remainder of tattoo healing process.
DO NOT soak tattoo in shower, tub or ocean/pool or expose to direct sun or tan for 2-3 weeks.
After tattoo has fully healed, apply a high SPF to avoid sun damage.
DO NOT use other products unless directed by your artist.
If red bumps or a rash occurs you may be using too much lotion or allergic to what you are using.
If swelling and redness persist please see a physician.
The first touch-up is on us.:)
Please call or email with any questions: 508-339-2001 - Tues-Sat 12-9pm
www.ai-taiidsoultattoo.net
1. Remove bandage in one hour.
2. Wash tattoo well with a mild fragrance -free soap & lukewarm water. Rinse with cold water.
3. Air dry for 10-15 minutes or gently pat dry with paper towel. No wiping.
4. Apply a small amount of a fragrance -free lotion to your tattoo until absorbed into the skin
about 3-4 times a day or as needed.
Tattoo will flake/peel like sunburn: DO NOT PICK OR SCRATCH TATTOO.
Carefully apply fragrance free lotion as needed for remainder of tattoo healing process.
DO NOT soak tattoo in shower, tub or ocean/pool or expose to direct sun or tan for 2-3 weeks.
After tattoo has fully healed, apply a high SPF to avoid sun damage.
DO NOT use other products unless directed by your artist.
If red bumps or a rash occurs you may be using too much lotion or allergic to what you are using.
If swelling and redness persist please see a physician.
The first touch-up is on us.:)
Please call or email with any questions: 508-339-2001 - Tues-Sat 12-9pm
www.ailaiidsoultattoo.net