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Home My WebLink AboutAnna Michener 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: 4 This is to certify that: ANNA MICHENER IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS V1 Tattooing ❑ Body Piercing C_'� Both located at: ART AND SOUL 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 2/7/2019 American Red Cross CPR/AED -Adult Certificate expires: 2/712019 Bloodborne Pathogens Certificate expires: 2112/2019 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 NichaeCNcCCean, Chairman Commonwealth 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: 4 This is to certify that: ANNA MICHENER IS HEREBY GRANTED A PERMIT FOR A BODYART PRACTITIONER AS 7 Tattooing C Body Piercing 7 Both located at: ART AND SOUL 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 2/1/2019 American Red Cross CPR/AED -Adult Certificate expires: 2/1/2019 Bloodborne Pathogens Certificate expires: 2/2512018 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 gilichaeCblcCCean, Chairman Town of Mansfield - Board of Health Town Pak ko arigfield §� z' 1IV(0}Njfield, MA 02048 Practitioner's Application for Offering Tattoo or Body Piercing Services OPERATOR NAME: ANNA MICHENER Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: 12/25/1977 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: 35 HIGHLAND AVENUE CITY: MANSFIELD STATE: MA ZIP: 02048 MAILING ADDRESS: 35 HIGHLAND AVENUE CITY: MANSFIELD STATE: MA ZIP: 02048 PHONE NUMBER OF OPERATOR: (508) 272-4164 EMAIL OF OPERATOR: TATTOOSBYANNA@HOTMAIL.COM PLACE OF EMPLOYMENT AS A PRACTITIONER: ART AND SOUL ADDRESS: 88 COPELAND DRIVE CITY: MANSFIELD STATE: MA ZIP: 02048 PHONE NUMBER OF ESTABLISHMENT: (508) 339-2001 TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) Tattooing Body Piercing Both PROJECTED DATE FOR BEGINNING OR RENEWAL: 12/31/2017 IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: I F � ( ( S 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? _v Preventing transmission of infectious diseases for tattoo and piercing? j 4 Course work /training on human anatomy (body piercing only)? / Course work /training on skin diseases, disorders and conditions for tattoo and piercing? L ,� 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: 3H1299-- 2 � American Red Cross CPR/AED - Adult Certificate expires: •-2F261261'g" 21-12-019 Bloodborne Pathogens Certificate expires: ,2i25/M-9- ZI Zb Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: V�GC..Ct CI `7+rc4-t'Li..E'...� d ...� ( 1`c. t'f�G - C'y" C?�.. �.� `'"' i.�I,T G'c'• When shaving of a site or area is necessary, will you use: Disposable razors LjY'es I I No Non-dispo*le razors LI Yes F.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; Page 2 of 2 Date Quality Training: When you want it, where you want it. ' ' Bloodborne for Body Art 1 This course includes the following objectives and is consistent 1' with OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 � � � and body art safety 1 1 a ProTrainings.COm company -Infection Control for Body Mists -Regulated waste ' -How Bloodborne Pathogens are spread -Body Fluid Cleanup Procedures 1 ' This card certifies that the individual has successfully completed the -HfV and AIDS -clove Removal -Hepatitis B Virus and Vaccine -Handwashing i ' education in OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 -Hepatitis C wus -Sterilization Procedures for Body Art Shops 1 and body art safety -Skin Diseases -Exposure Incident and Reporting 1 _ -Medical Issues With Body M -Reducing Risk 1 1 ANNA MICHENER -Sagineedng and work Practice Controls -cross Contamination has completed training In Bloodbome Pathogens for Body Art ' 1 1 Date Issued: 25 Feb 2017 Renew By: 25 Feb 2018 ' Instructor: ROY W. SHAW 1 . Certificate 4 148804999561901 sats a-7481 tattoo.probloodbome.com suppod@protrainings.com 1 HEARTSAVER FIRST AID CPR AE® HeartsaVer® 6"'R American Hl First Aid CPR AED Assocatfon® Anna Michener The above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heareaver First Nd CPR AED Program. , Optional completed modules are those NOT marked out: Child CPR AED Infant CPR 2 Exam 02 02/07/17 / —�-- 19 Recommended Renewal Data Issue Date 1 R HEARTSAVER FIRS' AID CRR AE® Training I TC ID # Center Name Emergency Training Specialists MA20625 TC Info Norton, MA 02766 (508),285-6020 '.. Course Location Mansfield, MA '.. Instructor Inst. ID # Name Shawn R. Simmons 04080801196 Holder's Signature 02015 nedcanrteart W3tioo ramµ'ng Wa c,sc dwniave ftsappe e, 15-1812 I I \ Quality Training: When you want it, where you want it. Dear Anna, Above you will find your Bloodborne for Body Art certification card. You may also access this page at a later time by logging into tattoo. probloodborne. com and clicking the Print Certificate button. 1 1 Bloodborne for Body Art This course includes the following objectives and is consistent g i 1 with OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030i"r 1 1 and body art safety 1 ja ProTralnings.com company -Infection Control for Body ARlsts -Regulated waste i 1 -How Moodborne Pathogens are spread -Body Fluid Cleanup Procedures 1 This card certifies that the individual has successfully completed the 1 -HIV and AIDS -Glove Removal i education in OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 -Hepatitis a Mous and vaccine-Handwashing 1 and body art safety -Hepatitis Cvirus-Stmflhnflon Procedures for Body Art Shops 1 -Skin Diseases -Exposure Incident and Reporting 1 1 1 ANNA MICHENER -Medical Issues With Body Art -Reducing Risk 1 -Engineering and work Practice Controls -Cross contamination 1 1 has completed training in Bloodborne Pathogens for Body Art 1 -Course is 2 contact hours 1 1 1 1 Date Issued: 12 Feb 2018 Renew By: 12 Feb 2019 Instructor: ROY W. SHAW #100 1 1Certificate # 151845936661901 888466-]48] tattoo. rebloodborne.cam support protrainin8s.com1 1 Dear Anna, Above you will find your Bloodborne for Body Art certification card. You may also access this page at a later time by logging into tattoo. probloodborne. com and clicking the Print Certificate button.