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HomeMy WebLinkAboutTiki Tattoo -12/31/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit for Offering Tattoo or Body Piercing Permit Number: 1 This is to Certify that TIKI TATTOO 12 PRATT STREET MANSFIELD IS HEREBY GRANTED A PERMIT FOR A BODYART ESTABLISHMENT (TATTOO AND PIERCING) This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires on December 31, 2009 unless sooner suspended or revoked. Dr. Raymond Martin, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Offering Tattooing or Body Piercing Services ESTABLISHMENT NAME: TIKI TATTOO ADDRESS: 12 PRATT STREET CITY: MANSFIELD STATE: MA PHONE NUMBER OF OPERATION: (508) 337-8454 NAME OF OWNER DONALD J. HOWE ADDRESS: 18 MARTHA'S WAY CITY: FRANKLIN STATE: MA PHONE NUMBER OF OWNER: (508) 440.5773 ZIP: 02048 ZIP: 02038 NAME OF CORPORATION / ASSOCIATION / PARTNERS SBD BODY ART, INC. NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT OR MORE IN THE CORPORATION / ASSOCIATION / PARTNERSHIP: MAILING ADDRESS FOR APPROVAL NOTIFICATION AND RENEWAL: 18 MARTHA'S WAY, FRANKLIN, MA 02038 TOTAL SIZE OF OPERATION IS: 1,200 SO. FT. FT. PROJECTED DATE FOR BEGINNING OPERATION: OR IF RENEWAL PUT DATE HERE: 12/31/2008 IF A TIME LIMITED EVENT, NAME AND ADDRESS OF EVENT: DATE OF EVENT Bloodborne pathogens must be renewed every year. American Red Cross CPR/AED - Adult must be renewed every year. American Red Cross Standard First Aid certificate must be renewed every 3 years. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PLEASE INITIAL YOUR RESPONSES Will procedures be maintained and documented that ensure all persons performing body piercing or tattooing services on the business premises have received appropriate training: Initials Tattooing or body piercing? ,�// I✓I yes ❑ no RR First Aid? / yes ❑ no Preventing transmission of infectious diseases? ❑ no Universal precautions against blood borne pathogens? ,�es V yes ❑ no Appropriate tattoo and body piercing after -care? yes ❑ no Will written records of equipment utilized by the business be maintained? ?(yes ❑ no Will procedures be maintained that ensure that all non -disposable equipment, parts of V,/ yes ❑ no equipment or instruments used in performing procedures are disinfected and sterilized in accordance with the Code? Will weekly biological monitoring tests of the business's heat sterilization devices be ❑ yes per,/ � no VAC�Atk, completed? Will a record of all tests performed on the heat sterilization devices be maintained for �s ❑ no at least two years? Please describe your procedures for remedial action to assure compliance with the sterilization requirements in the event a test indicates a heat sterilization device is not functioning properly: �� � Sri l � z✓�1 t_w� w � �1-1�.e__�c, s �v�c� �2� � � �� l--U,� � �- �° �__ And all hand sinks equipped with: Liquid or granular soap? yeses ❑ no Hand drying facilities? Oyes ❑ no Waste receptacles? (Q yeses ❑ no Hot and cold water? "yes ❑no Are there any overhead or otherwise exposed sewerage lines so as to create a ❑ yes /no potential hazard to the sanitary environment of the business? Will sufficient and appropriate receptacles be provided for the disposal of refuse and ,ye, ❑ no -- single -use instruments ? Will all waste items including but not limited to needles, razors and other supplies '" yes ❑ no capable of causing lacerations or punctures be disposed of in accordance with the applicable standards of Chapter 3745-27 of the Administrative Code? Will indoor and outdoor refuse containers have lids? V1yes ❑ no _. Page 1 of 3 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Is your water provided by a public authority private well ❑ If a private well, attach EPA approval. Is the building connected to a municipal sewer Vl� private sewage disposal system If a private system, attach EPA approval. // Will all plumbing work be done under permit from a plumbing authority? 0/ yes ❑ no Will a mop sink be provided for the disposal of mop water? V—/Q s ❑ no Will a mop sink be located out of the tattooing and body piercing area? V"yes ❑ no Will procedures be maintained that ensure the general health and safety of all V yes ❑ no individuals employed by the business? Will a permanent record be maintained that includes the dye colors, lot number or other V"yes ❑ no identifier of each pigment used for each tattoo? Each area in which tattooing or body piercing is conducted will have an area of how many square feet? Will all areas used for performing services be separated from each other and from [eyes ❑ no wailing customers or observers by a panel or a door? Is at least 40-foot-candles of light being provided at all areas where tattooing or body ey's ❑ nc piercing services are performed? Is at least 20-foot-candles of light provided at all other areas? V(Yes ❑ nc Describe the floor finish material directly under equipment used for tattooing or body piercing services: V C 1 --- - Will all tables and other equipment be constructed of easily cleanable material, with a Vyes ❑ nc smooth washable finish? Will toilet room facilities be available to the employees and customers of the business? Vj yes ❑ nc Are all toilet rooms equipped with: Toilet tissue dispensers? (] nc A mechanical exhaust fan or screened, openable window? Vyes V yes ❑ nc Self -closing room doors? /es ❑ nc Is there a hand sink in each toilet room and tattoo and body piercing area? ;?"yes ❑ nc Number of sinks J Page 2 of 3 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Is the potable water supply protected from cross -contamination? yes ❑ no Describe the storage facilities for employee's personal belongings (i.e. coats, boots, purses, etc.) AT\ci o %l\dU' COUA Will live animals be excluded from the area used for tattoo or body piercing procedures? Plas ❑ no Will a separate area be provided where employees and patrons may smoke or yes ❑ no consume food or beverages? O�h_ Please describe your procedures to assure that individuals under eighteen years of age will not be served without proper consent: Q-W _ate \—i(Q✓l't 5t1i c✓ Y�od Will disposable latex gloves be available and changed accordingly? VIYIS ❑ no When shaving of a site or area is necessary, will you use: Disposal razors 121 or Non -Disposable razors 0 Please describe how sterilized instruments and equipment will be stored. - Sher,\' ce-J c(��k p6C Ve, ' v\ SO\F _Sec,\ UAM vie w\ t r\i) V1 A( &-AC,A AC6 Will an ultrasonic type device be used to clean and disinfect non -disposal needles and Pwj yes ❑ no instruments? - - Will a steam sterilizer (autoclave) be used to sterilize all non -disposal needles and V yes ❑ no instruments? If no, please describe how this will be done. Please describe how you will monitor and document the sterilizer function. Ae5r'_ VW &-CACk ,V &Itin. - A r' o1oa-Q Mtbdme CovApItkmac' Co . Por, k',�sho lx Signature Date: Page 3 of 3 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 Please Print Le0bly Business/Organization Address: City/State/Zip: Phone #: c57)'8 I-( An _ 15 Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3. We are a corporation and its officers have exercised 9. ElEntertainment their right of exemption per c. 152, § 1(4), and we have I0. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12`.�Other SArACP_ *Any applicant that checks box 01 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 41. I am an employer that is providing worriers' 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 lrgreby_cedifyLundler the pains and penalties of perjury that the information provider/ above is true and correct. ' r i') — Phone #: — Q _�, " r-1 O — L q _�, 3 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/din 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. Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 020 - ao ---1 ` -I 1 ** 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.