DRAFT - Body Art Facility Permit

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

MonthDayYear
Date
Establishment Name*
Establishment Address (physical and mailing)*

Street Address

Street Address Line 2

CityState / Province

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

Name of Legal Owner*

First NameLast Name
Type of Legal Owner:*
Provide the name of all individuals comprising legal ownership and their mailing addresses:*

Fee*

Permit Fee

$300.00 Quantity

Total

$0.00

I hereby certify to the best of my knowledge that the foregoing information is correct. I agree to abide by TriCounty Health Department’s Body Art establishment regulations. I understand that this permit is revocable for non-compliance with health department rules and regulations. The health department will be allowed inspection access to the establishment and the establishment's records. I understand that this permit is non-transferable.
Applicant's Signature

Clear
Should be Empty: