New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Public Health and Food Protection Program

PO Box 369

Trenton, NJ 08625-0369

APPLICATION FOR TANNING FACILITIES REGISTRATION

(AUTHORITY: N.J.S.A. 26:2D-81 et seq., particularly 26:2D-88)	FOR STATE USE ONLY
Amount Rec’d:	$_______________

Certified Check	#_______________

Money Order	#_______________

Date:	_____/_____/_____

Transmittal No.	#_______________
Registration Status:

Initial Registration

Annual Renewal Registration

Change of Registration Information

The Application for Registration shall be accompanied by a single certified check (i.e., cashiers check) or money order, and shall be made payable to “Treasurer, State of New Jersey.”

Personal checks shall not be accepted.	FEE SCHEDULE

Initial Registration or Annual Renewal Registration:

$300.00 (includes first ten sunlamp products) plus $10.00 for each additional sunlamp product over the first ten.

Change of Registration Information:

No fee required

$300.00 + [$10.00 x (number of sunlamp products >10)] = $
Instructions:

For Initial Registration: Complete all information requested on this Application form.

For Annual Renewal Registration: Update the Initial Registration Application with any new or corrected information.

For Change of Registration Information: Update the Initial Registration Application with any new or corrected information.
FACILITY INFORMATION
Name of Tanning Facility

Facility’s Permanent ID Number

Telephone Number

Email Address

Street Address

Mailing Address (if different)

City	State	Zip Code

City	State	Zip Code

FACILITY OWNERSHIP

(Attach an additional sheet, if necessary.)
Name of Owner

Telephone Number

Email Address

Street Address

Mailing Address (if different)

City	State	Zip Code

City	State	Zip Code

Name of Owner

Telephone Number

Email Address

Street Address

Mailing Address (if different)

City	State	Zip Code

City	State	Zip Code

FACILITY OPERATION
Days and Hours of Facility Operation

Primary Type of Business in which the Tanning Facility is located:	Number of Sunlamp Products Provided in the Tanning Facility:

Tanning Salon Beauty/Nail Salon Health Club/Fitness Center
Other

Provide the following information for each ultraviolet lamp or sunlamp product:
Manufacturer
Model Number
Type

(Bed, Booth, Facial, Other)
Attach an additional sheet, if necessary.
Names, addresses and telephone numbers of the tanning equipment suppliers, installers and service agents, if appropriate:
Name
Address
Telephone Number
Indicate whether Supplier, Installer or Service Agent
Attach an additional sheet, if necessary.
Names of all trained tanning facility operators:
Name
Name
Name
Attach an additional sheet, if necessary.
In addition to this completed application form, the applicant shall provide the following required documents to the Department for review:

Copy of the operating and safety procedures unique to the tanning facility;

Copy of the information and/or instructions provided to consumers of the tanning facility;

Outline of the Operator Training Curriculum; and

Documentation that tanning facility operators have satisfactorily completed required training as specified in N.J.A.C. 8:28‑3.11, including the names of trainer and/or training program.
CERTIFICATION BY APPLICANT
I have received and read the New Jersey Tanning Facilities Standards, N.J.A.C. 8:28-1et seq., and I certify that this tanning facility meets these standards. I realize I will be liable for fines and/or sanctions specified in the standards if I fail to correct violations of these standards as cited by the Department or local board of health. I certify that statements made in this application are true, complete and correct to the best of my knowledge and belief.
Name of Applicant (Print)

Title

Signature of Applicant	Date

1

APPLICATION FOR TANNING FACILITIES REGISTRATION

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PHSS-1

AUG 16	Page 2 of 2 Pages.

AUG 16	Page 1 of 2 Pages.

PHSS-1, Application for Tanning Facilities Registration

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2015-10-30

NJDOH