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
Amount Received: $_____________ Date: ___/___/____

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

Name and Address of Establishment

Telephone Number at Mailing Address

( )	Telephone Number at Establishment Location

( )
Name of Operator

Fax Number

( )	E-Mail Address

If any of the above information has changed, check the appropriate box(es) and make the correction(s) below:
Owner/Corporation Name
Establishment Location
Mailing Address
E-Mail Address
Tel. # at Mailing Address	( )
Tel. # at Location	( )
Establishment Name
Operator
FAX Number	( )
ESTABLISHMENT INFORMATION
Names of Corporate Officers:	Names of Partners:
Name of all practitioners:	Describe Body Art performed:	Please submit the following information:

Municipal zoning approval

Approval from local construction official

Inventory of processing equipment, jewelry, inks

Description of all services provided

Photograph, negative biological of autoclave

Manufacturer’s instructions for the autoclave

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 HBV vaccine series

Policies for latex allergies

Written agreement with physician

(Body piercing and permanent cosmetics only)

Renewal applications need only submit changes to the above information
Practitioner:
Specialty:
1.	1.
2.	2.
3.	3.
4.	4.
5.	5.
6.	6.
Please Submit Qualifications for the following:

Operator

Practitioner

Apprentice

Renewal applications need only to submit the Names and Qualifications of new staff.
Water Supply

Municipal Well	Waste Disposal

Sanitary Sewer Septic System	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-34 OCT 02

Permanent

New Jersey Department of Health and Senior Services

Charles Davenport

2002-11-01

Elaine White

NJ DOHSS/EEOH/CEHS/PHSSP