Department of Health

APPLICATION FOR APPROVAL TO OPERATE A BODY ART ESTABLISHMENT

(AUTHORITY: N.J.A.C. 8:27-1 et seq.)

Type of Establishment

Tattoo	Permanent Cosmetics

Body Piercing	Ear Piercing	FOR DEPARTMENT USE ONLY
Tattoo	Other:
Amount Received: $_____________ Date: ___/___/____

( Check ( Money Order Check No.:
Body Piercing
ESTABLISHMENT IDENTIFICATION
Name and Mailing Address of Owner or Corporation

Address of the Event

Name of Operator or Convention Manager

( )
Telephone Number at Mailing Address

( )	Telephone Number at Establishment Location

( )
Fax Number at Mailing Address

( )	Fax Number at Establishment Location

( )
Email Address

( )	Email Address

( )
Names of Corporate Officers/Partners:	Address of Corporate Officers/Partners:
ESTABLISHMENT INFORMATION
Please submit the following information:

Photograph, negative biological of autoclave

Manufacturer’s instructions of autoclave

Location of processing area

Location of sink

Manufacturer’s instructions ultra-sonic equipment

Type of containers used to transport soiled equipment

Policies and procedures for sterilization

Policies for control of back to original practitioner

Record keeping

Method of transport of sterile supplies back to practitioner

Samples of packaging material and chemical integrators

Please submit the following information:

Purpose for which the permit is requested

Floor plan drawn to scale

Description of all services provided

Name and addresses of all practitioners

Medical waste generator ID number

Policies for collection of regulated medical waste

Policy regarding minors and system to monitor

Copy of malpractice insurance for each practitioner

Copy of informed consent for each procedure

Copy of after care instructions for each procedure

Copy of client application

Policies for hand washing

Samples of waterless hand washing agent

Policies for reporting infections and injuries

Written instructions provided to each artist before event

Please instruct all practitioners to bring a current copy of a Negative Biological for the autoclave used to process equipment prior to the event.
Outline of any training programs offered at the event:

Alcohol on premises?

Yes	No	Hours of Operation:

Days of Operation:

CERTIFICATION BY APPLICANT
I have received and read Chapter 8 of The New Jersey State Sanitary Code and I certify that this Body Art Establishment meets these standards. I understand that obtaining a permit by means of fraud, misrepresentation or concealment shall result in closure of the Body Art Establishment. I certify the statements made in this application are true, complete and correct to the best of my knowledge and belief.
Name of Applicant (Print)

Title of Applicant

Signature of Applicant	Date

EHS-35 OCT 02

Temporary

New Jersey Department of Health and Senior Services

Charles Davenport

2002-11-01

Elaine White

NJ DOHSS/EEOH/CEHS/PHSSP