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HomeMy WebLinkAboutDonald J. Howe 12/31/2009Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Practitioner's Application for Offering Tattoo or Body Piercing Services OPERATOR NAME: DONALD J. HOWE Please attach recent identification photograph, here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: 7/9/1966 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: 18 MARTHA'S WAY CITY: FRANKLIN MAILING ADDRESS: 18 MARTHA'S WAY CITY: FRANKLIN PHONE NUMBER OF OPERATOR: PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: 12 PRATT STREET STATE: MA ZIP: 02038 STATE: MA (508) 440-5773 TIKI TATTOO zip: 02038 CITY: MANSFIELD STATE: MA Zip: 02048 PHONE NUMBER OF ESTABLISHMENT: (508) 337-8454 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: 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. First Aid and CPR Certifications? Preventing transmission of infectious diseases? Course work / training on human anatomy? Course work / training on skin diseases, disorders and conditions? Universal precautions against blood borne pathogens? Appropriate tattoo and body piercing after -care? Certificate Type is AMERICAN RED CROSS STANDARD FIRST AID Certificate Type 2: AMERICAN RED CROSS CPR/AED-Adult Certificate Type 3: BLOODBORNE PATHOGENS Initials �es No k/Yes i No O Yes 0-No Yes No El es C] No Yes D No Certificate 1 expires: 5/31/2009 Certificate 2 expires: 5/3112007 Certificate 3 expires: 12/13/2007 Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: Must have state license or I.D. Photo copies of such are taken of each. When shaving of a site or area is necessary, will you use: Disposable razors Non -disposable razors Other: 16 Yes [] No Yes 0 No 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: ate) Date: �a G Page 2 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 54�11�(�Ct�l�AA tlln4 A (AtW Address: i 9', )Am sa r Phone #: 54'K 44go - 5 }'1-3 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail ,ofpart-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2m a sole proprietor or partnership and have no ?. ❑ Office and/or Sales (incl. 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I LEI Health Care with no employees. [No workers' comp. insurance req.] 12,❑ Other`-1 AAJ ye Q '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 #l. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. 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 DIA for insurance coverage verification. I do her certify, under the pains an f lienalties ofperjuty 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 Heath 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone www.mass.gov/dia hi 4a r ; 40, cl kk� 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. UCJ Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.