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Home My WebLink AboutArt & Soul Tattoo, LLC 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 This is to Certify that: Permit Number: 2 ART AND SOUL TATTOO, LLC 88 COPELAND DRIVE 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: ART AND SOUL TATTOO, LLC Nov d f' ADDRESS: 88 COPELAND DRIVE CITY: MANSFIELD STATE: MA ZIP: 02048 PHONE NUMBER OF OPERATION: (508) 339-2001 -_- NAME OF OWNER ANNA N. MICHENER ADDRESS: 35 HIGHLAND AVENUE OR 88 COPELAND DRIVE CITY: MANSFIELD STATE: MA ZIP: 02048 PHONE NUMBER OF OWNER: (508) 272-4164 .. _..___..____._ ... .... EMAIL OF OWNER: TATTOOSBYANNA@HOTMAIL.COM NAME OF CORPORATION / ASSOCIATION [PARTNERS ART AND SOUL TATTOO, LLC NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR MORE IN THE CORPORATION / ASSOCIATION / PARTNERSHIP: N/A PLEASE DESCRIBE YOUR PROCEDURES TO ASSURE THAT INDIVIDUALS UNDER EIGHTEEN YEARS OF AGE WILL NOT BE SERVED WITHOUT PROPER CONSENT ALL CUSTOMERS MUST PRESENT A STATE OR FEDERAL ISSUED ID THAT IS NOT EXPIRED. MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: 35 HIGHLAND AVENUE, MANSFIELD, MA 02048 TOTAL SIZE OF OPERATION IS: 750 SQ. FT. FT. PROJECTED DATE FOR BEGINNING OPERATION: OR IF RENEWAL PUT DATE HERE: 12/31/2017 IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT 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: Initials attooing r body piercing? ✓es no 44-L- — First Aid? Lvdyes ] no ,, M,, ,, Preventing transmission of infectious diseases? [.✓yes ❑ no Universal precautions against bloodborne pathogens? ;✓es [] no Appropriate tattoo and body piercing after -care? [�� /Yyes ❑ no n Will written records of equipment utilized by the business be maintained? [/yes ❑ no Will procedures be maintained that ensure that all non -disposable equipment, parts of ;.yes-,;� no equipment or instruments used in performing procedures are disinfected and sterilized in accordance with the Code? r+on-wt I Will wee#(y biological monitoring tests of the business's heat sterilization devices be„✓es i.__j no e�ti, completed? Will a record of all tests performed on the heat sterilization devices be maintained for �. Eyes ;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: NE?"Ia--ech is C0-0- cQ, a-++et1,hUuf1V1,.t devl,6e is rroVJ-e wk't(c, And all hand sinks equipped with: �,/ Liquid or granular soap? L! yes j__I no Hand drying facilities? [✓es ❑ no 'vL vv Waste receptacles? Yes [_] no Hot and cold water? 1-4yes i`I no _ Are there any overhead or otherwise exposed sewerage lines so as to create a yes fv no ' 41 potential hazard to the sanitary environment of the business? Will suffiicient and appropriate receptacles be provided for the disposal of refuse and [_ yes ,� no 41111 single -use instruments ? Will all waste items including but not limited to needles, razors and other supplies '..'yes f " 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 no V`-- Page I 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 private well If a private well, attach EPA approval. Is the building connected to a ✓municipal sewer LI private sewage disposal system If a private system, attach EPA approval. Will all plumbing work be done under permit from a plumbing authority? L-ryes ❑ no Will a mop sink be provided for the disposal of mop water?Iv/yes I !I no Will a mop sink be located out of the tattooing and body piercing area? [i✓yes J no Will procedures be maintained that ensure the general health and safety of all [✓Yes [I, now individuals employed by the business? Will a permanent record be maintained that includes the dye colors, lot number or other ✓yes �..'�. now 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? -10 Will all areas used for performing services be separated from each other and from [✓yes ❑ no y� V— 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 F,:'yes ❑ no piercing services are performed? Is at least 20-foot-candles of light provided at all other areas? I ✓yes ['`{ no � "V Describe the floor finish material directly under equipment used for tattooing or body piercing services: fvc Will all tables and other equipment be constructed of easily cleanable material, with a Leyes ❑ no a�'W smooth washable finish? Will toilet room facilities be available to the employees and customers of the business? FYI "Yes El no ! /1�✓ Are all toilet rooms equipped with: Yes Toilet tissue dispensers? i [ ] no A mechanical exhaust fan r screened, openable window? ( /yes [ _I no Self -closing room doors? [✓yes �_ no pA-tom- Is there a hand sink in each toilet room and tattoo and body piercing area? ✓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? V`yes I._ j no Describe the storage facilities for employee's personal belongings (i.e. coats, boots, purses, etc.) CACfoorvl h6c- S CAhI`n-2tS _ -_---- __ Will live animals be excluded from the area used for tattoo or body piercing procedures? /yes ` l no t` l 51'1f•5 W i+l^ Will a separate area be provided where employees and patrons may smoke or ✓yes I no consume food or beverages? �I - Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: ^ \fa,lM_s_+a4-e_y✓ - Me�v-AHLii tS5ue-J (� to aired a Q c(t C',V�+C; Will disposable \ / gloves be available and changed accordingly? [es no When shaving of asite or area is necessary, will you use: Disposal razors ✓ or Non-Dispo ble razors (--OCOSS 't^---- Please describe how sterilized instruments and equipment will be stored. 6ej Cab j'n fi-S CV- CLrrxwe�, 5 . Will an ultrasonic type device be used to clean and disinfect non -disposal needles and _Yes f_ _! no instruments? Will a steam sterilizer (autoclave) be used to sterilize all non -disposal needles and Ir/es I. _. no °-- instruments? - -- - - If no, please describe how this will be done. Please describe how you will monitor and document the sterilizer function. S wt S V"Od-elfw� I t t l S" - ore -[es-f , `f4uz.->'- we_run eqC 4-o `�i i otM j2e S v 11S cvw- via I i i o vveu�r�- i led +esfis Dire rv,f. 'A r wlkoPr_f jL . Signa re Date: Z/ 111/2-4 7 - 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0-32_-(eli�-75 s1 **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. The Commonwealth of Massachusetts Department of Industrial Accidents y I Congress Street, Suite 100 Boston, MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMTTTING AUTHORITY. Applicant Information g Please Print Legibly Business/Organization Name: t '4 ` bOJ `cc- 4Z? LA-C ` M an(A City/State/Zip: HOVI'�T)4<. Phone ` 9-00 1 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with S employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar[EatingEstablishment 2: ❑ I am a sole proprietor or partnership and have no 7, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $• ❑ Non-profit 3. ❑ [No workers' comp, insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 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, 12.0 Other ��OC.1 with no employees. [No workers' comp. insurance req.] *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 tbemsclves, but the corporation has other employees, a Workers' compensation policy, is required and such ao organizationshould checkbox#I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: L h-'\ �V ` S Cc % U I G'Yl E �=-,� Y5� ' f- t�✓t C �' c iO?S v?> i, 3t3& lnsurer'sAddress: (�' (i �� - Z-� t i��tF�-4't�S'��`s C`J }""l C'. �� i1 City/State/zip:i [�Ct tS q 1 G G 2L Policy # or Self -ins. Lic. #- V V C. Expiration Date: J 1 ,�, 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 DL4 for insurance coverage verification. I do hereby c ,under thepa 'ns and p�en�lKes of perjury chat the Information provided above s true and correct Ripnature: i �_4'. G'i,(,.'�... f ` 6 - `'�. `t-�4�G '.`'� Date: l (/ 12-( l " Gv i( 7"?} ( 2 C) 0 l 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: Phone#: a� o® CERTIFICATE OF LIABILITY INSURANCE DPTE(MMIODYYYY) 11/27/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C & S INSURANCE AGENCY INC P O BOX 406 MANSFIELD MA 02048 NAMNT EACT Debra Gerraughty ._ ___ acoN 2 EX) (508)339-2951 nc No: _ noorsless: dabble@candsins.com INSURER(SI AFFORDING COVERAGE NAIC If INSURERA: LM INS CORP 33600 _ INSURED ART AND SOUL TATTOO LLC 88 COPELAND DRIVE MANSFIELD MA 02048 INSURERS: _ INSURER C:__ INSURERD: INSURERE: ._ INSURER F: n^wEn Ar_oe CFRTIFICATF MIIMRFR- 919177 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR LTR TYPE OF INSURANCE DL AD INSD SUBR Won POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDOIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR _ DAMA ET RRG ENTED — PREMISES (Ea cccurmnea $ MEO EXP (Any one parson) $ _ _PERSONAL &ATV INJURY $ N/A AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ GEN'L PRODUCTS-COMPIOPAGG _ $ POLICY JECT a LOG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accltlenl $ BODILY INJURY IPer person) $ ANY AUTO BODILY INJURY (Per accidenu $ ALL OWNED SCHEDULED ..._ AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A — PROPERTY DAMAGE Per ---- $ UMBRELLALIAB Ll OCCUR EACHOCCURRENCE $ AGGREGATE _ 5 EXCESS LIAB CLAIMS -MADE NIA DED RETENTION is A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA (MandatoryinNH) NIA NIA WC531 S386428017 05/30/2017 05/30/2018 �/ X STATUTE ERH E.L. EACH ACCIDENT $ 100,000 - E.L. DISEASE - EA EMPLOYEE $_100.000 E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, desalba untler DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at w .mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Mansfield MA 020, �'.) ( ( � C Daniel M. Cr rvey, CPCU, Vice President — Residual Market — WCRIBMA n ae0.R_,n1A ACr1Rrt CrYRPnPATIrTM All rinhlc rwca-up ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Board of Health -Art and Soul Tattoo, M. - 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 art: 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., Comnadin: can thin blood and interfere with blood clotting); Hepatitis or HIV infection. I certify with my initials the following 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. I 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: State: Zip: Date of Birth: License ID #: Tattoo Design: 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: y W ID cr L- 2 v w o � �.� 'JO K o `C O Tww � O CD O CS ti N 3 mgz w O • O 0 � O. G �CD p w a w o' o Q. 00 a �' °0z v a rq � o ti vQa °- � �`` � • ,.,. � r. p Q- b o cfDo N �. O O p O M '-' O O � A,� w O p i7 CIO 0 � � P"' •.rn+ � b W � O CAD .w+ 0 n "tea ID 0 0 H c? : Q � O CD i C W ti O O CD rp 'TOE' x W (?Q i wo o�iew;oq�O euueAgsoo;;e; aauayaiW euuy