Tooele Health Department

Establishment Name

Phone Number

Street Address

Mailing Address

Tooele County Health Department

151 N. Main Street, Suite 140 - Tooele, UT 84074

Phone (435) 277-2440 Fax (435)277-2444

www.tooelehealth.org

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:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

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:

$100.00

Total:

$100.00

'Please Select Method of Payment to Continue'

Payment Information:

Method of Payment:	Credit/Debit Card eCheck
Update Name from Above

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

Submitting ...