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HomeMy WebLinkAbout2018 Application 1�*N Sfq( Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address S( RA Phone Number: (860) 337-6173 Fax: (860) 644-1930 TATTOO LICENSE APPLICATION Please review and provide the requested information for your establishment. Incomplete or unpaid applications will delay the issuance of your license.Any license issued pursuant to this application will be subject to applicable State and South Windsor Regulations. Licenses are not transferrable. Name of Establishment: 1 Address of Establishment: Phone & E-mail of Establishment: / o—/ *r11�c(O1'1 Name of Manager/Operator*: Phone Number for 24-hour Emerge y Contact: l9'� Name of Legal Owner: E: LI Address for Legal Notices: �lJ it LC-4 I lq-f > License Fee:$50.00 per to on Typ e vices Provided:En Tattoo❑ Body Piercing❑ Permanent/semi-permanent makeup❑ Other �Qttoo Technician License Information: *Please use the back of f this form if additional space is needed NAME STATE LICENSE NUMBER PA cyo-D Dnw_ �.�� ater Supply: t Public❑ Private (well) Sewage S pply: [! Public❑ Private (septic) Is food or beverage provided for the public on site? YES ❑ NO HOURS OF OPERATION Ll SUNDAY to / If YES, please describe: � (g _ L7-EICE W 4- fJ� Po-pS MONDAY P to y TUESDAY t)Mto g 10 Applicant ature Date WEDNESDAY to THURSDAY � � to P FRIDAY I to Please Print Name [:IATURDAY Office Use Only: Date Paid: Check Number: Cash: Other: Rev 7/5/18 Contest Information License Information Name: MEGAN EILEEN BOYLE Agency:Department of Public Health Mailing Address:881 farmington ave,west hartrord,CT 06119 Dlvislon:Practttloner Licensing and Investigations Section Main Address: 881 farmington ave,west hanford,CT 06119 Type: Tattoo Technician-Training Permit small: meganbg4@sboglobal.net Number:TAT-STONT Phone: 8609709918 Status: PENDING Supervises Credential I Supervision Inactive Supervisor Supervisor Credential Supervisor Credentlal # Supervisee Credential type Status Date Name # Type TATSTDNT `I Tattoo Technician-Training ANGELO ELIA TAT.0000245 Tattoo Technician BOARD OF HEALTH CONMIONWEALTH OF MASSACHUSETTS 413-587-1224 CITY OF NORTHAMPTON JOANNE LEVIN,M.D.,CHAIR bSASSACHUSET 1 01060 DONNA SALLOQM SUZANNEFFICE OF THESUZANNE Sh11TH,h1.D. C INTH1A A.SUPOIS,PhD BOARD OF HEALTHWILLIAMS HARGRAVES 212 MMN STREET >tERRiDiIH O•LEARI',R.,S,D1Fi£CTOR Body Art ftt=itioner Permit No: BHP-2018-0255 License Fee: $50.00 Issue Date: 07/11/2018 In accordance with rules and regufations pro mufgated 6y The VorthaMpton Board yweafth governing BodyArt Practitioncrs and Body Art Establishments, a nprm�f � to: Dennis DeMarzio Whose pface of business is.- T Armory Street E In Northampton,. 9�" Type of business: Body Art Practitioner Expires: 12/31/2018 Dims_tcK of Public Health LICENSE MUST BE POSTED IN A CONSPICUOUS PLACE ON PREMISES MASSACHUSETTS DRIVER'S LICENSE k� NOT FOR FEDERAL ID s3a z 09/M2018 3 3893 D: WNE !NE F--Wi:L'+_C} CNUCH1 A i` F kmLS RD HA WDUL VA 0034_9666 �a BRO p",n;�u s' 06/22/87 i American AcademyorCAR & First Aid, Inc.. This is to cerl that DENNIS DEMAR230 bas completed the course in Blood Borne Pathogens This incliridan/has sncar�ful/y con�ple/ed/Ix nborc mar6oned rnrirset and has 1kmonslivial prnfirnnry in flx .riil�r�y Gy p��fring Jlx exanunalion. it/ ru�airlu»cc Hill) tJn terms and rnndifion of A»ierium Academr a/' CT'R crud First Ail ►,rc: !?irerror of Truiarns Certi/ilQ1YON NNIIJIAE'1' lssac Date Reneww! Dale jelwgir GoDaai, ivt t: THE EDGE TATTOO CO., L.L.C. RELEASE I, the undersigned, have requested The Edge Tattoo Co., L.L.C. ("Edge Tattoo")to tattoo my I understand that there is some degree of risk to my health in the requested prcedure(s) in any event, and especially if I fail to properly care for the area of the procedure in accordance with the Instructions for basic body modification, set out below. I, furthermore, understand that If I have diabetes, or if I am taking medication to reduce blood clotting, or if I fail to properly care for the area of the procedure in accordance with the medication to reduce blood clotting, or if the area of the procedure Is already inflamed or irritated (as for example by reason of infection or injury), I should not undergo this procedure except with the consent of a physician. Finally, I understand that one or more of the preparations I might use to prevent infection in the area of the procedure may cause an allergic reaction and result in adverse medical complications. This release has been requested of me, as well as the representations contained in this document, as material consideration and inducements for The Edge Tattoo Co., L.L.C., to undertake the requested procedure(s). Having read this document entirely, including the instructions for basic body modification care set out below, I hereby release and forever discharge The Edge Tattoo Co., L.L.C., its successors and assigns, and its employees, Independent contractors, agents and respective heirs, executors, administrators, successors and assigns, from all manors or liabilities, claims, actions and demands, in law or equity, which I or my heirs, executors, administrators and assigns might have by reason of complying with my request for the procedure(s). I represent to you that: (1) 1 understand the terms and conditions contained in this document and that all of my questions, if any, have been answered to my satisfaction. (2) 1 am not suffering from diabetes, hemophilia, allergies (other than those disclosed below), discoloration, swelling, lumps or other signs of irritation in the area of the procedure. (3) 1 realize the importance of proper care of the area of the procedure in permitting normal healing, without infection, and commit to faithfully follow the instructions for basic body modification care, set out below. (4) 1 am aware that cameras are in use throughout the studio. (5) 1 am over the age of 18 years, and if not, 1 am over the age of 16 years, and all legal guardians, whose signature appears below, has consented to the requested procedure(s): Description of tattoo: Please print the correct spelling and numbers of the lettering you are going to have tattooed on you today below: The Edge Tattoo Co., L.L.C., its owners, members,employees, independent contractors and agents, make no representations, guarantees or warranties, express or implied, regarding the spelling of any tattoo or the meaning, interpretation,translation and/or symbolic nature of any tattoo. Customer represents that they have thoroughly researched the spelling of any tattoo as well as the meaning, interpretation,translation and/or symbolic nature of the selected tattoo, and agrees to have it applied to their body. Customer hereby expressly agrees to idemnify and hold harmless The Edge Tattoo Co., L.L.C., its owners, members,employees, independent contractors and agents from any claims,suits or actions regarding the spelling of any tattoo as well as the meaning, interpretation,translation and/or symbolic nature of any tattoo. Signature: Date: Name: Time: Address: Age: Town: State: Zip: Phone Number: Are you pregnant or nursing? Yes No Are you allergic to latex? Yes No Are you allergic to betadine or iodine? Yes No Are you allergic to any antibiotic preparations? Yes No. If so please identify? All of these records are accurate and true: Yes Signature: Signature(s)of all legal guardians: Name: _Date: Name: Date: If you are a sole custodian, please initial: By signature I am consenting to the requested procedure and joining in the release and representations contained in this document. The Edge Tattoo Regulated and Infectious Waste Disposal Procedure All tattoo needles are single use gas sterilized needles manufactured and packaged by high quality and reliable manufacturers. Needles are disposed of into sharps containers after each tattoo is completed. When the sharps container is full, it is sealed and placed in a medical waste box, when that box is near it's fill point or weight regulation of 40lbs and at least once per calendar year, it is picked up by a licensed medical waste disposal company. The box is kept in an employee only area, which clients have no access to at any point for any reason. The specific company can vary based on availability and cost. Currently the studio's contracted medical waste disposal company is BioSery until the end of 2020. A f--re Ir CE Here at The Edge we want 10 ensure you have a happy,sale and effective healing process.In order to meet these promises we use a product called Saniderm. a clear bandage that is applied to your tattoo after completion.If your artist does not use saniderrn,follow the verbal instructions they gave you in the studio, HOW TO CARE FOR YOUR TATTOO WHILE WEARING SANIDERM Keep 11 on for 24 hours. Normal showering and activity is fine,however do not excessively soak,submerge it under any water,or expose it to any pool,ocean,rarer,lake,or pond water.If the Santderm begins coming off,do not slick it lack down,instead remove the plastic early. Additionally,the Saniderm will accrue body fluids and ink under the wrap,your tattoo is not failing out or staining your skin.However,if you notice water under the wrap,then it also must come oil early.After the 24 hour period,remove the Saniderm-We recommend doing this slowly after cleaning your hands with antibacterial soap and soaking it thoroughly In a long warm shower.Once removed,simply wash the area We guarantee our work and offer free touch ups within the first four months with the gently with antibacterial liquid soap using warm water and skin to skin contact. artist who originally did your tattoo,This policy does have some exceptions depending Afterwards let If air dry. on the area of the body the tattoo is located.There are a million different ways that pule claim the healing process should be handled,this method Is what we HOW TO CARE FOR YOUR TATTOO AFTER REMOVING SANIDERM recommend,as this is what has worked best for us. Please do not refer to the advice of a non-professional or an artist who did not do your tattoo for something as important as Still keep it out of any previously described water for 2 weeks.Wail until the area is the safety of your body and the quality of your permanent artwork. completely air dried to apply any moisturizer.The main theme of how to moisturize your tattoo is to apply it frequently and lightly.Ensuring that only enough to keep the area If you have any question on your tattoo during the heating process,please call our moisturized is applied,as you do not want to suffocate the area with over application of studio at: the moisturizer.The first week of moisturizing will be done using Aquaphor,no other (8W)644.1021 ointrnenls such as ABD,Neosporin,or triple antibiotic will heal the tattoo properly. or by email at: Follows the first week,an unscented and u artists@theedge.tattoo n9 undyed lotion will be used,a thicker lotion such as a Palmer's Coacoa Butler is best as it requires less frequent reapplication.11 or any product slings when applied,do not use it again,There should be no visible (your artist's name)@theedge.tattoo moisturizer left on the skin.ft you do over apply or if your skin looks slimey, to ask them directly then moisturize to the areas around the tattoo,don't wipe away the excess. or Moisturize throughout the day,at least 7limes per day,for the first 4 weeks.After that By direct message on their Instagram taper off to at least 3 times per day for the next 3 weeks.There Is no maximum amount of times,just do not over apply.If the skin looks like dry skin or tools itchy,then moisturize again.The tattoo area will look red and irritated for a bit,this is normal,as you did just get stabbed with a needle.During the healing process it is also normal for the area to flake and maybe lightly scab,DO NOT PICK OR SCRATCH AT YOUR TATTOO,rather continue to moisturize.Contact your tattoo artist with any questions or concerns,we are here for the entire process and to answer any questions you may have.Clean bedding and clothing are important,as dirt,body oils and other substances can find their way into your now tattoo. THINGS TO AVOID For the first 3-4 weeks,please avoid any activity that would involve soaking the skin or the tattooed area such as hot tubs,baths,swimming In pools or ocean water,pedicures, ate....Regular showering is fine.The tattoo only needs to be cleaned with antibacterial soap the one time that the bandage comes off.Any further cleaning should be done in a normal daily shower with soap that does not irritate your skin or sting.DO NOT WASH EXCESSIVELY,4 will dry your tattoo and cause Improper healing.It is VERY Important to keep a new tattoo out of the sun,as the skin is already traumatized.Any other damage such as a sun bum will have increasingly adverse effects on your new tattoo healing property.The most important thing to do in the long term is to use SPF 45 or stronger sunscreen,reapplying every 2 hours anytime your tattoo is subject to the sun. The sun can damage Tattoos through clothing,so UPF clothing or using SPF under your clothing is the best way to remain prolecled.Keep in mind that the sun can fade your tattoos at any point Therefore,if you want to keep those pigments bold,bright,and beautiful and details from blobbing up,than invest in sun protection.Apply this at least every 2 hours and do not use alcohol based or aerosol sunscreen. �T"N IC Et> THE EDGE TATTTOO EMPLOYEES AND RESPONSIBILITIES ANGELO ELIA: Owner/Tattoo Technician Oversee and maintain proper sterilization and cross contamination preventation procedures. Maintain contracts with land owner, utilities, and medical waste providers. Maintain legal records of clients. Maintain and oversee all Tattoo Technicians' CT Tattoo Licenses Provide tattoo services. Provide sterile and high quality tattoo and cleaning supplies. Provide high quality and safe equipment and pigments for tattoo services. Provide necessary training to employees. Supervise tattoo services conducted by apprentice MEGAN BOYLE. PEIGHTON PLOURD: Receptionist Execute informed consent. Organize legal records. Establish appointments for tattoo services. BRYANT SETZLER: Tattoo Technician Maintain CT Tattoo License. Maintain proper sterilization and cross contamination preventation procedures. Provide tattoo services. Provide high quality and safe equipment and pigments for tattoo services. NICHOLAS PINTO: Tattoo Technician Maintain CT Tattoo License. Maintain proper sterilization and cross contamination preventation procedures. Provide tattoo services. Provide high quality and safe equipment and pigments for tattoo services. DENNIS DEMARZIO: Tattoo Technician Maintain CT Tattoo License. Maintain proper sterilization and cross contamination preventation procedures. Provide tattoo services. Provide high quality and safe equipment and pigments for tattoo services. MEGAN BOYLE: Receptionist/Tattoo Apprentice Execute informed consent. Organize legal records. Establish appointments for tattoo services. Maintain CT Tattoo Learner's Permit. Maintain proper sterilization and cross contamination preventation procedures. Provide tattoo services under the supervision of permitted supervisor ANGELO ELIA. Provide high quality and safe equipment and pigments for tattoo services.