HomeMy WebLinkAboutSamantha Gromczynski -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. 7
This is to certify that: SAMANTHA GROMCZYNSKI
IS HEREBY GRANTED A PERMIT FOR A BODY ART PRACTITIONER AS
0 Tattooing ❑ Body Piercing 1:1 Both
at: TKI TATTOO
12 PRATT STREET
MANSFIELD MA 02048
American Red Cross Standard First Aid Certificate expires: 2/3/2012
American Red Cross CPR/AED - Adult Certificate expires: 1/2912010
Bloodborne Pathogens Certificate expires: 111412010
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. Raymond 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: Q nn tknt ie�c� .7 rJ. Sk. \
Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches
in size. Clear photocopies are acceptable.
DATE OF BIRTH: - 'I
(A practitioner shall be a minimum of 18 years of age.)
RESIDENCE ADDRESS: 3 o
CITY: �17 STATE: A A ZIP:
MAILING ADDRESS:
CITY:
STATE: ZIP:
PHONE NUMBER OF OPERATOR: 1-Q,—I _ Zb „ .;�y t ---1
PLACE OF EMPLOYMENT AS A PRACTITIONER:
TA
ADDRESS: l 2- :l A -•TT J +l
CITY: L\ A fI F I C- 7 STATE: -k k ZIP: e5 z 6 g 6
PHONE NUMBER OF ESTABLISHMENT: !J0 -S � -T . rn Ljc-, q
TYPE OF PRACTITIONER PERMIT APPLYING FOR: (Check all that apply)
Tattooing
® Body Piercing
Both
PROJECTED DATE FOR BEGINNING OR RENEWAL: T ' , t i 9
IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT:
DATE OF EVENT:
Page t 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 bloodborne pathogens?
Appropriate tattoo and body piercing after -care?
American Red Cross Standard First Aid Certificate expires: Z ,3
American Red Cross CPRIAED - Adult Certificate expires: .21
Bloodborne Pathogens Certificate expires: '] - t o
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:
Z'Yes
pinitials
t� No
ees
[g No
0 Yes
[No(
WJfes
U No
04es
O No
ReYes
pj No - 6l
es ® 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:
Date: 'q . 46 7
Page 2 of 2
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This certifies that
Samantha
B/oodborne
Pathogens
For the Community and Workplace
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