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


Please put N/A for any fields that are not applicable
Operator Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:
Operator Date of Birth
Operator Gender
Name of Body Art Establishment Where Employed
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 Operator Permit.
Signature
Date

Permit expires two (2) years from blood borne pathogen completion date.

All applicants must provide:
*Current blood borne pathogen-training certificate. Course available at:

New operators must also provide:
*Aftercare instructions (signature & date line), Sec 5.1
*Medical release form, Sec 6.1
*Inventory and Body Art Procedures Sec 3.1
*Proof of Hep. B vaccination series, Sec. 3.13

*If aftercare and medical release forms are the same forms used by an already permitted body art establishment then no need to provide another copy.

If you have additional documents to send, please email them to eh@tooelehealth.org.
Body Art Operator Permit (2 years):   $25.00   Item Subtotal:  
$25.00
Late Fee If Applicable:   $   Item Subtotal:  
$0.00
Total:
$25.00
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