San Juan County Public Health
             
San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838

Application for Body Art Establishment and Operator Permit
*Completed application and fee of $130.00 must be received before a permit will be issued.


Establishment Information
Organization Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

Name of Property Owner
Name of Applicant
Phone Number
Street Address
Mailing Address (if different than street address)
Applicant is:
Individual
Partnership
If partnership, list names and number of each partner

 
Applicant agrees that maintenance of a health permit is predicated on compliance with the
San Juan County Health Regulations for Body Art Facilities.
This permit is revocable for non-compliance.
Permit is valid for one year from date of issue.
Applicant's Signature

Artist/Operator Registration
In addition to the Body Art Establishment Permit, Body Art Operators must be registered by filling out the information below and must comply with regulations set forth by San Juan County Health Department.

NOTE: If you will have more than one operator at your establishment you MUST fill an Operator Registration form for EVERY operator. You can find the form on our website at SanJuanPublicHealth.org
Name of Body Artist/Operator
Address of Operator/Artist
City
Phone Number
Operator Date of Birth
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. A course is available at:
*Please note that the course link above is not required. Any bloodborne pathogen course is acceptable as long as you have proof of training.
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

*Aftercare and medical release forms may be the same forms

Body Art Establishment Permit:   $100.00   Item Subtotal:  
$100.00
Body Art Operator Permit:   $30.00   Item Subtotal:  
$30.00
Total:
$130.00

*An inspection is required and will be performed by our Environmental Health Director. Inspection is by appointment only. Please allow up to 5 (five) business days for completion of inspection. Our Environmental Health Director will contact you to schedule an inspection.

Payment Information:
Processing Fee Rates:
Cards:2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:$0.75
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
 
Submitting ...
SIP Program & Data © 2006-2021 Instant Payments All rights reserved.
~ Terms & Conditions ~ Privacy Policy ~ Contact Us ~
SIP Version 3.07.14803; (API: 2.18)
RSI Security PCI DSS Compliance