Loading...
HomeMy WebLinkAboutJoseph A. Clark - 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: 2 This is to certify that: JOSEPH A. CLARK IS HEREBY GRANTED A PERMIT FOR A BODYART PRACTITIONER AS W Tattooing ❑ Body Piercing ❑ Both at: TIKI TATTOO 12 PRATT STREET MANSFIELD MA 02048 American Red Cross Standard First Aid Certificate expires: 12/2212010 American Red Cross CPR/AED - Adult Certificate expires: 12/15/2009 Blood Borne Pathogens Certificate expires: 1/14/2010 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, Chair Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Practitioner's Application for Offering Tattoo or Body Piercing Services OPERATOR NAME: JOSEPH A. CLARK Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: 8/18/1963 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: 160 HOLLY ROAD CITY: MARSHFIELD STATE: MA ZIP: 02050 MAILING ADDRESS: 160 HOLLY ROAD CITY: MARSHFIELD PHONE NUMBER OF OPERATOR: PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: 12 PRATT STREET STATE: MA ((617) 719-1982 TIKI TATTOO zip: 02050 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. Initials First Aid and CPR Certifications? Fryps Ei No 1 Preventing transmission of infectious diseases? ErYes [i No < Course work / training on human anatomy? 0 Yes o No S� Course work/training on skin diseases, disorders and conditions? 0 Yes D No Universal precautions against blood borne pathogens? ltryes n No SC Appropriate tattoo and body piercing after -care? Yes Ej No Certificate Type is AMERICAN RED CROSS STANDARD FIRST AID Certificate 1 expires: 12/22/2010 Certificate Type 2: AMERICAN RED CROSS CPR/AED -Adult Certificate 2 expires: 12/22/2003 Certificate Type 3: BLOODBORNE PATHOGENS Certificate 3 expires: 12113/2007 Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: No tattooing anyone under 18. Must show I.D.-State I.D., passport, etc. When shaving of a site or area is necessary, will you use: Disposable razors X, Yes D No Non -disposable razors El Yes 1�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. ( '_ l Page 2 of 2 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 o/ Individual or 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: -N, 1T Mqq/v5(�el i"MA °�°k1 -� - 33? City/State/Zip: Phone #: 5 ' Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ 1 am a employer with employees (full and/ 5. ❑ Retail /t rpart-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ©" 1 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] S. ❑ 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. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I I ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12 with no employees. [No workers' comp. insurance req.] Other *Any applicant that checks box #1 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 #1. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy H 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 certify, under t pains nd penalties/Trrp)pe hat the information provided above is true and correct. ,�/`-01 /� Signature: w 1 L A Date: Q -c IS /K Official use only. Do not write in this area, to he completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gowma Phone C N � �. o E d e 499 1 This recognizes that Joseph Clark has completed the requirements for CPR/AED--Adult conducted by ARC of Massachusetts Bay Date completed 12/15/2008 The American Red Cross recognizes this certificate m valid for 1 year(s) from completion date. J fy.. I 4 A- 0 f I®® borne Pathogens ASHJ,,APPR0V CERTPFF'�►�jp�A�A�^ -was e A p HuYier's nalure has auvvesMIT camplQfed'e course In �n�l q (� �rf�t_� 6ui 814s1dhv[Oe,Pgthogens. _ A d Data Gomgnled Renewal Date ���Ce ler Pho Tralnirg Cenler Nole This Pmgam asslsls In satisfying the informaon and baining requireraats of the U.S. Determined of ®} Labor (OSHA, MSHA) add Mer agencies. This rand does not aM anml guarantee s8 provisions Moral American Safety & Health Institute ® by the standard here been meL Federal OSHA requires Nat bloodbome palhogens heard W qu rded at least annually to employees wind occupational o,,nam. Rate Nis Pmgam ongne al wnw.ashimlilme.mg An assadaf of wvlessional salary and health eiuratea scemwuwn orall(800)246-5101. he,