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Home My WebLink AboutLawrence Colaluca 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: VIMW • . 1115 1 Permit Number.' 14 IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS VI Tattooing I..1 Body Piercing ❑ Micropigmentation located at: ART & SOUL TATOO 88 COPELAND DRIVE MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: American Red Cross CPR/AED - Adult Certificate expires: 2/2612019 Bloodborne Pathogens Certificate expires: 212612019 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. qf Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Practitioner's Application for Offering Tattoo or Body (P/iercinng Services OPERATOR NAME: ��ce4 l q 1 fa�a , - %79/� CN (I C-- .. Please attach recent identification photograph here (with head and shoulders, front view.) approximately 20 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: ,t2/0– 00 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: �1 p y� J� »,i�f .Atl CITY: @c P .{.... tl ISTATE: ` ZIP: MAILING ADDRESS:4 1, Lj ST CITY: P PHONE NUMBER OF OPERATOR: EMAIL OF OPERATOR: I IN- 'I A _ _ PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDREStS�:— �f(p v tn�L,,.j. _oly- 1V CITY: Akio %' �_&. wSTATE: 4 ZIP: PHONE NUMBER OF ESTABLISHMENT: D� ( , 2?q -.260 1 TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply) Tattooing Body Piercing (] Both PROJECTED DATE FOR BEGINNING OR RENEWAL: IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: FEE: $25.00 Page 1 of 2 Q a Town of Mansfield Town of Mansff.eld - Board o f 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. P/ease 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? 1 Universal precautions against bloodborne pathogens for tattoo and piercing? Appropriate tattoo and body piercing after-care for tattoo and piercing? �� 1 ....... _. _. _ _.... -... . ` American Red Cross Standard First Aid Certificate expires; American Red Cross CPR/AED - Adult Certificate expires: Bloodborne 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: Yes L] No i Cl Yes xNo 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: _ 5�/L/� /� 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. Signature of Individual or Corporate Name 03(9- (9z-9o�1 "Social Security No. (Voluntary) or Federal Identification Number 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. The Commonwealth of Massachusetts Department of MdustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FLLED WITH THE PERMITTING AUTHORITY. Applicant Information n ' I Please Print Legibly Business/Organization Name: AY- 5UtA�T � `C(}60 Address: . 61� CV:fJM6k V V City/State/Zip: (`4aVIf — (d MA- Phone #: 5_6& 3361 200 Are you an employer? Cheek the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* el 6. ❑Restaurant/Bar/Eating Establishment 2. am a sole proprietor or partnersbip and have no ?• ❑ Office and/or Sales (incl. real estate, auto, eta,) employees working for me in any capacity. 8• Non-profit [No workers' camp. insurance required] 3, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per e. 152, §1 (4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, Other with no employees. [No workers' comp. insurance req.] 12.E] *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 thcrosclves, but the corporation has other employees, a workers' compensation policy is regmrea ana soon an organization should cbeck box #l. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company (usurer's City/State/Zip: Policy# or Seif-ins, Lic. #- 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 maybe forwarded to the Office of Investigations of the DIA for insurancercoverage verification. Ido hereby certify, •under the-paW' penaldes ofperjury 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 Person www.mnea.gu v,wa Phone I, Lawrence Colahica III, will be declining the hepatitis B vaccination shots. I acknowledge its significance and the risk I am taking. Lawrence,C6lah2(a III / ,2/,q/-)fJ/7 a ; • 0.0 t4-4 Z, 0 0 Quality Training: When you want it, where you want it. _________________e_,.o.._.._vo______-_oes...v__.._______e..____--- i i Bloodborne for Body Art This course includes the following objectives and is consistent 1 with OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 1 1 and body art safety 1 1 a ProTrainings.com company -Infection Control for Body Mists -Regulated Waste 1 1 1 -How 81oodMrne Pathogens are spread -Body Fluid Cleanup Procedures 1 This card certifies that the individual has successfully completed the -HIV and AIDS -Glove Removal 1 1 1 education in OSHA Bloodborne Pathogens Standard 29 CFR 7970.1030 -Hepatitis B virus antl Vaccine-Haoivritmng -Hap1 aodyArt Shops 1 rd -SlediuraIn and body art safety 1 Y Y idents aror Skin Diseases -Reposing Incident and Reporting 1 -5kio isaes -Medical Issues With Body Art -Reducing Risk i 1 LAWRENCE COLALUCA -Engineering and Work Practice eonbds-Cross Contamination 1 _ 1 -Course is 2 contact hours 1 has completed training in Bloodborne Pathogens for Body Art 1 1 1 1 Date Issued: 26 Feb 2018 Renew By: 26 Feb 2019 Instructor: ROY W. SHAW #100 _ 1 Certificate # 151973393632314 e8e-405-7487 timoo.pmbloodborne.com supporioprotrarmings.com 1 Dear Lawrence, Above you will find your Bloodborne for Body Art certification card. You may also access this page at a later time by logging intotattoo. probloodborne.com and clicking the Print Certificate button. Quality Training: When you want it, where you want it. 1 ' ProFi rstAitno Ba This Certification includes the following objectives and is consistent with national consensus 2015 ECCALCOR 1 1 and American Heart Association® Guidelines. 1 1 a PraTrainings.com company . -Adult CPR - Universal Precautions 1 1 1 - -AED -Diabetic Emergencies 1 1 This card certifies that the individual has successfully completed - Bleeding Control - Stroke 1 the National Cognitive Evaluation in accordance with ProTrainings - Musculoskeletal Injuries - Burns 1 Curriculum and the American Heart Association® guidelines - Poisoning - Bites and Stings 1 - Shock Management - Allergic Reactions LAWRENCE COLALUCA - Breathing Emergencies -Seizures 1 -Heart Attack -Heat and Cold Emergencies 1 has completed CPR & First Aid AED inclusive Certification P I 1, - Choking, Conscious and Unconscious 1 Date Issued: 26 Feb 2018 Renew By: 26 Feb 2020Instructor: 1 ROY W. SHAW #100 1 Certificate # 151973393632316 8sB-46-7487 baslc.profirstaidcom support®protrainings.com 1 L---------- —----------------- _---- __.. ----------------------J Dear Lawrence, Above you will find your ProFirstAid Basic certification card. You may also access this page at a later time by logging into. basic. prof irstaid.com and clicking the Print Certificate button. You will also receive a permanent copy of your card in the mail 5-7 business days after the date of purchase. Below is the mailing address to which we will mail your card. If there are any problems with any part of this card or address please let us know ProTrainings Customer Solutions Mon - Fri, 9am - 8pm EST Phone: 888-406-7487 Email: support@protrainings.com LAWRENCE COLALLICA 605 ADMIRAL ST PROVIDENCE, RI 02908-1427 US