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Home My WebLink AboutAnna Michener - 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 I Permit Number: 4 This is to certify that: ANNA MICHENER IS HEREBY GRANTED A PERMIT FOR A BODYART PRACTITIONER AS k Tattooing ❑ Body Piercing O Both at: TIKI TATTOO 12 PRATT STREET MANSFIELD MA 02048 i American Red Cross Standard First Aid Certificate expires: 12/2212010 I 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, Cha7Xan 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: ANNA MICHENER Please attach recent identification photograph here (with head and shoulders, front view,) approximately 2x3 inches in size. Clear photocopies are acceptable. DATE OF BIRTH: 12/25/1977 (A practitioner shall be a minimum of 18 years of age.) RESIDENCE ADDRESS: 121 GROVE STREET #1 CITY: FRANKLIN STATE: MA ZIP: 02038 MAILING ADDRESS: 121 GROVE STREET #1 CITY: FRANKLIN STATE: MA (508) 272-4164 PHONE NUMBER OF OPERATOR: PLACE OF EMPLOYMENT AS A PRACTITIONER: ADDRESS: 12 PRATT STREET 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) W Tattooing ❑ Body Piercing Both PROJECTED DATE FOR BEGINNING OR RENEWAL: P /l /Cj IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT: Page i 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? Bl�es o No 4fn (— 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? lees o No 10es n No Wes No plfyes o No [zYes No Certificate Type 1 AMERICAN RED CROSS STANDARD FIRST AID Certificate i expires: 12/22/2010 Certificate Type 2: AMERICAN RED CROSS CPR/AED - Adult Certificate 2 expires: 12/2212008 Certificate Type 3: BLOODBORNE PATHOGENS Certificate 3 expires: 1/15/2009 Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: No one under 18 will be tattooed. Must show proper (up to date) State ID/license or passport. When shaving of a site or area is necessary, will you use: Disposable razors Non -disposable razors Other: ees n No Yes RTNo 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: � (� ��C � J Date: 1� 0 Si Page 2 of 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. * Signature of 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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information I ^ Please Print Legibly Business/Organization Name:M � a N , 1p " l [ c' e' Re'y- Address: i 2 Mro_M i Mavis-fiMid M `j2 o , G f city/State/Zip:hone #: "5l 0 — 3�%' �i Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2. M I am a sole proprietor or partnership and have no y ❑ Office and/or Sales (met, real estate, auto, etc.) employees working for me in any capacity. 8. ❑Nom-profit [No workers' comp. insurance required] 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]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, rr 12.[`Other '17c D with no employees. [No workers' comp. insurance req.j *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 # I. I an: an emp toyer 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 Investifzations of the DIA for insurance coverage verification. I do hereby Phone#: 5�40 J a7, —Y/(0V 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 Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gowain i C N v0 a 9 N QYf - V O ' I � Bloodb®rne Pathogon� SHI-APP OVED ►ql Klp 4RD 1�s !n� P�(� An zeal In (PdnNJame) iVI l.MC�%2E'�tE'<� HONersSurohne hassucceaaulycomplatedaeoursein BAN 1 4 2009 JAN 1 4 2010 Blood¢plrt�'?ajhogena. Dale Comgated Renewal Dale Training Center Phone No. Traidoll Canter Note G TMsIxogmm aselas In satisfying the Informationand training requirementsof the US. Oepargnnnl ofLater (OSHA, MSHA) sortolhnr agences. This card dean not and cannot guarantee all Wotlsions Insured American Safety B Health Institute by the standard have been met Federal OSHA raciness that bloodemne Pathogens haning te Fawned! at An assedaton of prhomianal safety arll health educators sraexmnwr least Moody to employees with ecapalional exposure. Rate this program online at ana ashtmtitute.org t or car (Sall 246 5101. a- F Town of Mansfield SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER- No:2 Dept: Board of Health No:2 Dept Board of Health To the Departmental Officer making the Payment for the period Collections as per schedule of this date, filed in my office DL C 6 20011 VA Receipt of $ - Treasurer