HomeMy WebLinkAboutKerwin Chong - 12/31/2009Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Practitioner's Permit for Offering Tattoo or Body Piercing
Permit Number: 6
This is to certify that KERWIN CHONG
IS HEREBY GRANTED A PERMIT FOR A BODYART PRACTITIONER AS
0 Tattooing ❑ Body Piercing ❑ Both
at: TIKI TATTOO
12 PRATT STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires: 11/18/2009
American Red Cross CPR/AED - Adult Certificate expires: 11/2012010
Bloodborne Pathogens Certificate expires: 12/1/2009
This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires
on December 31, 2009 unless sooner suspended or revoked.
MANSFIELD BOARD OF HEALTH
Dr. Ra l on Martin, Chairman
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
OPERATOR NAME: KIW I I V C*
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH:
(A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS: C I Z i tom. S
CITY: -Awn-
STATE: Py ZIP:
MAILING ADDRESS:
CITY:
STATE: ZIP:
PHONE NUMBER OF OPERATOR: 0 I } -
PLACE OF EMPLOYMENT AS A PRACTITIONER: I 1
ADDRESS:
CITY: "76 p AI STATE: ZIP:
PHONE NUMBER OF ESTABLISHMENT: 91 ' j+ — "r4
TYPE OF P CTITIONER 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.
Initials
First Aid and CPR Certifications? LVI/Yes No lw
Preventing transmission of infectious diseases? Lr Yes Ei No tt(�'
Course work / training on human anatomy? IM '--ra T�-6 &fl-tj
r�
Course work / training on skin diseases, disorders and conditions?
Universal precautions against blood borne pathogens?
Appropriate tattoo and body piercing after -care?
American Red Cross Standard First Aid Certificate expires:
!. American Red Cross CPR/AED - Adult Certificate expires: U/ 'MID
Blood Borne Pathogens Certificate expires: I q s-nel
Please describe your procedures to assure that individuals under eighteen
years of age will not be served without proper consent:
03
When shaving of a site or area is necessary, will you use:
Ei Yes ❑ No
� e- El No
Yes ❑ No
Yes ❑ No
Disposable razors L111'Yes u No
Non -disposable razors L Yes E) 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: Date: lei
Page 2 or 2
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.
* Signaturd of Individual
Corporate Name (Man ory)
By: Corporate Officer
(Mandatory, if applicable)
0fz-02- q
** 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
lvww.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: j- ((AJ"uv C4-FNc]
Address: nz-
City/State/Zip: AVM kA- M 7V Phone #: 6 o- — Spar, 3 q f W
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ Retail
Xr part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] & ❑ 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 I0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑� dalth Caree �,y
with no employees. [No workers' comp. insurance req.] 12. Other I c v ei 6t
*Anv annlicant that checks box #1 must also fill out the section below showing the
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 All.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Nay
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 DIA for insurance coverage verification.
I do hereby certifyiundeh thy, pains and penalties of perjury that the information
Official use only. Do not write lit this area, to be completed by city or town official
City or Town:
Permit/License
true and correct.
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.moss.gov/dia
Phone