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 Massage Establishment Plan Review

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

Business Owner's Information
First Name: Last Name:
City: State/Province: ZIP/Postal Code:

Establishment Name
Phone Number
Street Address
Mailing Address

PLAN REVIEW CHECKLIST                                                                                      DATE RECEIVED

Scale drawing of floor plan, Sec. 7.3 (Permanent Structure)/Layout setup(outcall/annual temp.)       ________________
Plan review fee, Sec 6.3                                                                                                                       ________________ 
                                                                                                                                                                                                (Receipt #)
The hours of operation of the establishment or outcall massage service, Sec 7.4                                ________________

The number of employees, Sec 7.5                                                                                                                         ____________________

The equipment, instruments, and materials to be used, Sec 7.6                                                                     ____________________

The methods of sterilizing or disinfecting equipment and instruments, Sec 7.7                                         _____________________

Storage area for instruments and supplies, Sec. 8.1 (F)                                                                                     _____________________

A copy of your license to perform massages by the Utah
Division of Occupation and Professional Licensing, Sec. 7.9                                                                _________________

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 Massage Establishment Health Permit. Permits may be revoked or suspended for violations of Tooele County Health Department Regulation #6. Permits are non-transferable.

Message Estblishment Plan Review:   $100.00   Item Subtotal:  

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Payment Information:
Method of Payment:
  Credit/Debit Card
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Routing Number:
Account Number:
Name on Card:
Account Number:
Expiration Date:
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