Tooele Health Department
             
Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435)277-2444

Application for Body Art Establishment Plan Review

Please put N/A for any fields that are not applicable

Owner's Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

Establishment Name
Phone Number
Street Address
Mailing Address

Types of Services Offered (mark all that apply)
Tattooing
Permanent Makeup
Body Piercing
Branding

PLAN REVIEW
                                                       
                                                          


  • Plan review fee, Sec. 11.1 Receipt#
  • Solid Partitions or walls from rooms that may cause potential contamination, Sec. 11.2
  • 45 square feet floor space or each operator, Sec 11.4
  • Minimum 1 had sink/3 operators and lavatory, Sec 11.7
  • Storage area for instruments and supplies

Forms
  • Disclosure statemet (provided by TCHC), Sec. 5.1
  • Notice for filing a complain (provided by TCHD), Sec 5.1
  • Medical release form, Sec 6.1
  • Inventory and Body Art Procedure
  • Minor, parental consent form, Sec 7.1, 3.10, 15.1
  • Establishment and Employee information, Sec 3.1
  • Inventory and Body Art Procedure, Sec 3.1

All of the above statements are true. I understand that any false information on this application may be cause for denial or revocation of my Body Art Health Permit. Permits may be revoked or suspended for violation of
Tooele County Health Department Regulation #10.
Permits are non-transferable.


BODY ART ESTABLISHMENT PLAN REVIEW:   $100.00   Item Subtotal:  
$100.00
Total:
$100.00
Payment Information:
Method of Payment:
 Update Name from Personal/Organizational Information
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
 Change Payment Method
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