DRAFT - Body Art Facility Plan Review

Body Art Facility Plan Review
A Bloodborne Pathogens Certificate is required. To complete the course, you may visit: Pacific Medical Bloodborne Pathogens Training
Date

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Person's Phone Number
Please enter a valid phone number.
Facility Name:*
Facility Address (physical and mailing)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone Number*
Please enter a valid phone number.
Facility Email
example@example.com

Owner's Name*

First NameLast Name
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Phone Number*
Please enter a valid phone number.
Owner's Email*
example@example.com

Artist's Name:*

First NameLast Name
Artist's Phone Number*
Please enter a valid phone number.
Type of body art to be performed*

The following items MUST be addressed on the plans:
- Plans for establishment, including square footage and general floor plan
- Equipment, instruments, and materials to be utilized.
- Names and addresses of suppliers of body art equipment
- Body art procedures to be used
- Sterilization procedures to be used
- Documentation to be used as per TCHD Regulations for Body Art
- Signage
Upload Complete Plans*

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Upload Blood Borne Pathogens Course Certificate*

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Fee*

Plan Review Fee

$200.00 Quantity

Total

$0.00

Credit Card

Signature

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