AMANDA GILLESPIE WITCH CITY INK - ESTABLISHMENTS Amanda Gillespie — Witch
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Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970 puLitaHeatth
Kimberley Driscoll TEL. (978) 741-1800 FAX. (978) 745-0343 Larry Ramdin, MPH, REHS, CHO
Mayor health@salem.com Health Agent
BODY ART HEALTH PERMIT
Permit#
BA-17-31 License For : Body Art- New Apprentice
Date of Print
8/30/2017 Granted To: Amanda B. Gillespie/Witch City Ink
Permit Issued
8/30/2017 Address: SA Herbert Street Salem MA 01970
Permit Expires
12/31/2017 Location of Establishment: 186-3 ESSEX STREET
Permit Fee
$135.00 Restrictions: Permit to practice as an apprentice @ Witch City Ink
Late Fee
$0.00 Notes:
This permit or license is granted in conformity with the statues and ordinances relating thereto,and expires on 12/31/2017 , unless
sooner revoked or suspended.
Larry Ramdin, MPH, REHS, CHO
Health Agent
O
,. .,. , City Of Salem, Massachusetts
Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970 PublicHeaIth
Kimberley Driscoll TEL. (978) 741-1800 FAX. (978) 745-0343 Larry Ramdin, MPH, REHS, CHO
Mayor health@salem.com Health Agent
BODY ART HEALTH PERMIT
Permit#
BA-17-32 License For : Body Art- New Practitioner
Date of Print
8/30/2017 Granted To: Amanda B. Gillespie/Witch City Ink
Permit Issued
8/30/2017 Address: 8A Herbert Street Salem MA 01970
Permit Expires
12/31/2017 Location of Establishment: 186-3 ESSEX STREET
Permit Fee
$135.00 Restrictions: Permit to practice body piercing
Late Fee
$0.00 Notes:
This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2017 , unless
sooner revoked or suspended.
Larry Ramdin, MPH, RENS, CHO
Health Agent
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
120 WASHINGTON STREET,C FLOOR
TEL. (978) 741-1800
KINMERLEY DRISCOLL / FAX(978) 745-0343
MAYOR J kundin@salem.com
LARRY RAmDiN,RS/REHS,mo,CP-FS
HEALTH AGENT
APPLICATION FOR PERMIT TO PRACTICE BODY ART
PERMIT FEE: $135.00 PER PRACTITIONER
APPLYING FOR: /
PERMIT TO PRACTICE BODY PIERCING j� \
PERMIT TO PRACTICE TATTOOING �1
PERMIT TO PRACTICE MICRO-PIGMENTATION IIIJJJ��1 \
PERMIT TO PRACTICE AS AN APPRENTICE
PERMIT TO PRACTICE AS A GUEST ARTIST J
NAME OF APPLICANT Arwndg 1J• h i ll e5 U 1 e
ADDRESS OF APPLICANT A NeYbey+ S+re2k
PHONE NUMBER OF APPLICANT 20 I — 59 S _G'3 fI7
NAME OF PERMITTED ESTABLISHMENT YOU WILL BE PRACTICING IN
WI+fk C�{�y -XVNK ADDRESS ISU-3 E-556x SWeer
An applicant for a permit shall show to the satisfaction of the Board of Health that he or she has compiled
with the following minimal training requirements for body art practitioners:
Applicant for this permit must show proof of age over 18 years as proven by a government issued photo
identification card.
Body art practitioners must perform body art only in permitted body art establishments.
Provide documentation for high school diploma, or its equivalent.
Provide certificate of completion of basic training in First Aid and CPR, as well as recertification
classes.
A certificate of completion of an OSHA course on the prevention of disease transmission and Blood borne
Pathogens.
Proof that you have held a license to practice body art for one year in another municipality or state, or have
completed at least one year of apprentice training as a tattooist under a licensed body art practitioner in the specific
discipline.
CITY OF SALEM, MASSACHUSETTS
` BOARD OF HEALTH
120 WASHINGTON STREET,4" FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR lramdin@n salem.com
LARRY RAMDIN,RS/RENS,CHO,CP-FS
HEALTH AGENT
For body piercers: 1.) Completion of an acceptable Anatomy and Physiology course. 2.) Proof of membership as a
Professional Member or Professional Member at Large by the Association of Professional Piercers, or an equivalent
professional organization.
For tattooists: 1.) Completion of an acceptable Anatomy course for tattoo practitioners for those applying for a
Tattoo Practitioners Permit. 2.) Proof of membership as a Professional Tattooist by the Alliance of Professional
Tattooists or an equivalent Professional Tattooing organization.
For Micro-Pigmentation Artists: 1.) Completion of an acceptable Anatomy course for tattoo practitioners for those
applying for a Tattoo Practitioners Permit. 2.) Documentation of successful completion of a one year micro-
pigmentation apprenticeship. 3.) Successful completion of forty (40) hours of formal training in a course approved
and certified by the American Academy of Micro-Pigmentation or equivalent Professional Tattooing
organization.
For Body Art Apprentices: In order to function as an apprentice, the qualifying individual must obtain from the
Board of Health a Tattoo Artist permit with the specification of the apprenticeship clearly stated. The
apprenticeship shall last no longer than two (2) years. The first year will focus on learning and class work,
including an acceptable anatomy course for body art practitioners. In addition, on the job training will address
general principals of set up including but not limited to observation, sterilization, clean up and bandaging. The
second year will focus on learning the art of body art.
For Permanent makeup/Micro Pigmentation Apprenticeship: Shall provide proof that he/she has achieved full
compliance with the requirements for Body Art Apprentices, and is continuously supervised while engaged in the
application of Permanent Make-up by a licensed Tattoo Artist who is authorized to perform Permanent Make-up
Application, and who is also certified by the Academy of Micro Pigmentation as an Associate Member.
For Guest Artists: The guest artist works under the auspices of the permitted body art establishment.
Practitioners will be limited to practicing no more that thirty (30) days per calendar year in the capacity of Guest
Artist.
I verify that I have read the Salem Board of Health Body Art Regulations. I have had the opportunity to ask
questions, and agree to abide by it.
Signature:. 6" Gia Date: g I I T7 I rI
In addition, pursuant to MGL C62 S49A, I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all
taxes required under the law.I7CG[7
Signature: 9 4, /% 04. Date: g I I�� I I P'
Updated 5/23/11
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health salem,com° ry
Mayor ■ @ Health A ent
F a . BODY ART-HEALTH PERMIT:
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Permit#
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SA-17-5 License For: Body Art-Existing Practitioner
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Permit Issued
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8/8/2017 Address: 8 A-Herbert Street#3 Salem. MA 01970 y ?.
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Permit Expires
Location of Establishment: ESSEX STREET
12/31/2017 s
i • ' Permit Fee r
$135.00 Restrictions: Tattoo Practitioner ■
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MAEIRIAGE CERTIFICATE
9 . No 20160524053`1938
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This rs to certify that the undersigned
(pant name and htla of.offictal pecfLrmmg marnage)
d1d on the 04 ?� day ofthe,monthpffha year20 Z/6 ,
Nevada,
(addressor church}; {Gty)
orn in lawful we& STEVEN W GILLESPIE
r `I of SALEM State/Country of MASSACHI3SETTS
i dateofbtrth. 01!21/1970 °. )
and AMANDA B CRONIN
of EFFINGHAM State/Country of NEW HAMPSHIRE
(C1Ly)
date of birth 08/19/1994 ij
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STATE OF NEW HAMPSHIRE
OFFICE OF PROFESSIONAL LICENSURE AND CERTIFICATION
Be it known that
AMANDA B GILLESPIE
has satisfactorily complied with and completed the statutory requirements set forth in RSA 314-A as a:
BODY ART PRACTITIONER
and is hereby licensed to practice the following in the State of New Hampshire:
BODY PIERCING
in witness whereof the Department has issued this license No. 2106B
sq M under the seal of the State of New Hampshire effective 07/02/2015
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ProTrainings hereby certifies that
AMANDA GILLESPIE
has successfully completed the education in OSHA Bloodborne Pathogens Standard 29 CFR
1910.1030 and body art safety
This course includes the following objectives and is consistent with OSHA Bloodborne Pathogens
Standard 29 CFR 1910.1030 and body art safety
-Infection Control for Body Artists -Regulated Waste .
-How Bloodborne Pathogens are spread -Body Fluid Cleanup Procedures
-HIV and AIDS -Glove Removal
-Hepatitis B Virus and Vaccine -Handwashing
-Hepatitis C Virus -Sterilization Procedures for Body Art Shops -
-Skln Diseases -Exposure Incident and Reporting
-Medical Issues With Body Art -Reducing Risk
-Engineering and Work Practice Controls -Cross Contamination
-Course is 2 contact hours '
Date Issued: 09/07/2016 Renewal Date: 09/07/2017
Certificate Number: 147329251850973
Instructor: ROY W. SHAW
ProTrainings 6452 E Fulton St.#1,Ada,MI 49301 888-406-7487 support®protrainings.com tattoo.probloodborne.com
CERTIFICATE of COMPLETION
This is to certify that:
Amanda Gillespie
has attended
Course Title - Adult CPR/AED
and has successfully completed the following elements
Adult CPR : valid 2 Years
AED-Adult : valid 2 Years
Conducted by
Instructor: Jessica Porcaro;
Oil
6/1212017
The American Red Cress is all authorized provider of 1ACET this course may be eligible for CEUs.
Contact your local chapter for details.
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