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 Health Card.
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/Employee information form, 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.

Application Fee:   $70.00   Item Subtotal:  
$70.00
Late Fee If Applicable:   $   Item Subtotal:  
$0.00
Total:
$70.00
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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