Body Art Facility Permit Application

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

Please note that any permits that are renewed after March 1, 2027 are subject to a late fee 50% of the original permit cost.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
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:

Please note that any permits that are renewed after March 1, 2026 are subject to a late fee 50% of the original permit cost.

Permit Fee

$300.00

Late Fee

$150.00

Total

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
Should be Empty: