Brenda Fitzgerald, MD Nathan Deal, Governor Olugbenga Obasanjo, MD, PhD, MPH, MBA District Health Director Kelly Wilson, Spalding Co. Environmental Health County Manager 1007 Memorial Drive P.O. Box 409 Griffin, Georgia 30224 770-467-4230 Fax 770-467-4265 BODY ART STUDIO APPLICATION New Application Renewal Application Type of Procedures: Tattoo Piercing Other (Please explain) Comments: Full/Legal Name of the Body Art Studio: Address of the Body Art Studio: Street City State Zip Phone Number of Body Art Studio: ( ) - Name of current landlord: Address of current landlord: Street City State Zip Phone Number of landlord: ( ) - Owner(s) of the Body Art Studio Address of Owner(s): Street City State Zip Phone number of Owner(s): ( ) - or ( ) - Owner(s) of the Body Art Studio Address of Owner(s): Street City State Zip Phone Number: ( ) - or ( ) - email If the Body Art Studio is a partnership, please list the names and address of all partners (attach additional sheet if necessary) If the Owner is a corporation, please provide a copy of corporation papers for our record.
Please provide the following with your completed application: A list containing the full names and home addresses of all employees and staff who will be working in the Body Art Studio. A copy of client informed consent statement and disclaimer of liability. A drawing of the facility, including the location of all furnishings, fixtures, storage areas, bio-hazardous waste containers, and equipment. This drawing must be to scale if you are a new Body Art Studio. Contact appropriate jurisdictions and comply with each jurisdictions applicable codes and requirements. Pay Applicable permit fees. Specifications on autoclave equipment or written statement that instruments used are all single-use. Please provide an example of the Studio s cleaning schedule to include surfaces to be cleaned, tasks or procedures to be Performed, types of chemicals/sanitizers used, and the location within the Studio. If the Studio performs body piercing, please provide manufacturer s specification on all jewelry. NOTE: A permit for a new Body Art Studio must be applied for at least 30 days prior to reopening if existing facility is remodeled, Renovated, or expanded. If there is a change of ownership or the physical facility is relocated, a permit for a new Body Art Studio must also be obtained. Body Art Studio Permits shall expire March 1 st of each year. This certifies that I have made application to the Spalding County Environmental Health Department for a permit as a tattoo/body piercing operator/artist. I grant permission to the duly authorized agent(s) of the Spalding County Environmental Health Department to inspect the body art studio(s) in my charge. I am cognizant of the Rules and Regulations of the Spalding County Board of Health relating to the body art studio(s) and I realize that non-compliance with said Rules and Regulations will be sufficient cause for the revocation of this permit should it be granted. Health Department permits are not transferable regarding ownership. The undersigned hereby applies for a permit to operate a Body Art Studio pursuant to the Spalding County Body Art Regulations and certifies that the Owner has received and read a copy of the rules. Signature Date
1. Does your equipment sink meet NSF (National Safety) Standards? yes or no 2. Are all furnishings of the Body Art Studio intact and functional? yes or no 3. Are cabinets for the storage of instruments, pigments, single-use articles, carbon, stencils, jewelry, studs, and Other supplies provided for each Body Artist? yes or no 4. Of what material are these cabinets made? 5. Are all surfaces of work tables, chairs, and furnishings constructed of material that is smooth, non-absorbent, Easily cleanable, and corrosion resistant? yes or no 6. What solution/chemical is used to sanitize furnishings after each procedure? 7. Is there a separate, designated area for eating and drinking for employees and customers? yes or no If yes, please explain 8. Where are single-use, sterile supplies stored? 9. Does this Studio perform Body Piercing? yes or no 10. Is all gauze used for procedures single-use and sterile: yes or no 11. How is antibacterial ointment dispensed for each procedure? 12. Are dyes and pigments dispensed into single-use containers? yes or no 13. Is a covered trash receptacle, that can be operated without the use of hands, available in each parlor? yes or no 14. Are leak resistant bags used to line these trash receptacles? yes or no 15. Are all instruments/equipment used in the Studio single-use? yes or no If answer is yes, do not answer questions 16-26. 16. Are used instruments cleaned and sanitized immediately after use? yes or no If answer is yes, do not answer questions 17-18. 17. Are used instruments soaked in an EPA approved disinfectant until cleaning can be performed? yes or no
18. What is the name of the disinfectant(s)? 19. Are all instruments, prior to sterilization, wrapped or packaged with a sterilizer indicator on each package? yes or no 20. Are all packages placed in the sterilizer labeled with the date and time of sterilization? yes or no 21. Is the sterilizer designed and labeled as a medical instrument: yes or no 22. Is a copy of the operator s manual for the sterilizer available? yes or no 23. How is the sterilizer cleaned? Please provide an example of the sterilizer log that must be kept for each load. 24. What is the name and address of the company that performs the commercial biological monitoring (spore) system. 25. What is the make/model number of the autoclave/sterilizer used in the Body Art Studio? 26. Where are all sterilized instruments and equipment stored? 27. How often are trash receptacles within the parlors cleaned? 28. What is the name of the company that picks up and disposes of all biohazard waste materials? And how often do the pick up these wastes? 29. Give examples, if any, of what items will be discarded into a non-sharps, biohazardous waste container. 30. How often is regular trash receptacles emptied? 31. How often is the commercial dumpster emptied? 32. What type of liquid/sewage waste disposal system is provided for the studio? 33. Where are client records maintained?
34. How long are client records maintained? 35. How are client records discarded after this time period? 36. What type of ointment/antibacterial solution(s) are used before, during and after body art procedures? I understand that approval is based upon the information I have provided within this application, with any documentation, and any drawings I have submitted. I will construct this facility according to these specifications. I also understand that any changes to the information submitted must have prior approval by the health authority before being implemented. Signature of Owner Print Name of Owner AREAS FLOOR COVING WALLS CEILING Equipment Storage Toilet Room(s) Garbage and Refuse Storage Equipment Wash Area Parlor 1 Parlor 2 Parlor 3 Parlor 4 Parlor 5 Hand Washing Area