Glinda Scott, Henry Co. Environmental Health County Manager

Brenda Fitzgerald, MD, Commissioner | Nathan Deal, Governor

Olugbenga Obasanjo, M.D., Ph.D., M.P.H., M.B.A. District Health Director Glinda Scott, Henry Co. Environmental Health County Manager 137 Henry Parkway, McDonough, GA 30253 District 4 Public Health Phone: (770) 288-6190 www.district4health.org

Body Art Studio Application

_____ New Application _____ Re-location _____Renovation

Type of Procedures _____Tattoo _____Piercing _____Other (please explain)

Comments:______

______

Body Art Studio Information

Full/Legal Name of Body Art Studio:______

Body Art Studio Address:______

City:______, GA Zip:______

Phone:______Fax:______

Days of Operation: (circle all that apply): S M T W Th F Sat Hours of Operation: ______

Appointment Only: Body Art Studio Owner Information Type of Ownership: ____Sole Proprietor _____Partnership _____Corporation _____Other

Owner’s Name(s): ______

Owner’s Address(es): ______

City:______, GA Zip:______

Phone:______Alternative Phone: ______

Email:______

*List names and addresses of all partners in a Partnership (attach additional sheets if necessary). *Provide a copy of Corporation papers if the Studio is a Corporation.

Please provide the following with your completed application:

_____ A list containing the full names and home address of all employees and staff who will be working in the Body Art Studio.

_____ A copy of client informed consent statement and disclaimer of liability.

_____ A copy of after-care procedures form.

_____ A drawing of the facility, including the location of all furnishings, fixtures, storage areas, bio- hazardous waste containers, and equipment. This drawing must be to scale if you are a new Body Art Studio.

_____ Contact appropriate jurisdictions and comply with each jurisdictions applicable codes and requirements.

_____ A copy of the Certificate of Occupancy for the Body Art Studio.

_____ Pay applicable permit fees.

_____ Specifications on autoclave equipment or written statement that instruments used are all single-use

_____ Please provide an example of the Studio’s cleaning schedule to include surfaces to be cleaned, tasks or procedures to be preformed, types of chemicals/ sanitizers used, and the location within the Studio.

_____ If the Studio performs body piercing, please provide manufacturer’s specification on all jewelry.

_____Written emergency plan in the event the primary autoclave/sterilizer malfunctions or tests positive for spores.

_____Review O.C.G.A Rules referencing Body Art

NOTE: At least 30 days prior to the expiration of a Body Art Studio Permit, the Owner shall submit an application to the Henry County Board of Health Environmental Health Section for a renewal of the Body Art Studio Permit.

Body Art Studio Permits shall expire on December 31st of each year. This certifies that I have made application to the Henry County Environmental Health Department for a permit of a Body Art Studio. I grant permission to the duly authorized agent(s) to the Henry County Environmental Health Department to inspect the body art studio(s) in my charge. I am cognizant of the Rules and Regulations of the Henry County Board of Health relating to the body art studio(s) and I realize that non-compliance with said Rules and Regulations will be sufficient cause for the revocation of this permit should it be granted Health Department permits are not transferable regarding ownership.

The undersigned hereby applies for a permit to operate a Body Art Studio pursuant to the Henry County Body Art Regulations and certifies that the Owner has received and read a copy of the rules. I have also received a copy of the O.C.G.A referencing Body Art Procedures and understand that non-compliance with said rules are a crime and punishable by law.

Signature: ______Date______

1) Does your equipment sink meet NSF (National Safety Foundation) Standards? _____yes or _____no

2) Are all furnishings of the Body Art Studio intact and functional? _____yes or _____no

3) Are cabinets for the storage of instruments, pigments, single- use articles, carbon, stencils, jewelry, studs, and

other supplies provided for each Body Artist? _____yes or _____no

4) Of what material are these cabinets made?

______

5) Are all surfaces of work tables, chairs, and furnishings constructed of material that is smooth, non-absorbent,

easily cleanable, and corrosion resistant? _____yes or _____no

6) What solution/chemical is used to sanitize furnishings after each procedure?

______

7) Is there a separate, designated area for eating and drinking for employees and customers?

_____yes or _____no

If yes, please explain______

______

8) Where are single-use, sterile supplies stored?

______

______9) Does this Studio perform Body Piercing? _____yes or _____no

10) Is all gauze used for procedures single-use and sterile? _____yes or _____no

11) How is antibacterial ointment dispensed for each procedure?

______

12) Are dyes and pigments dispensed into single-use containers? _____yes or _____no

13) Is a covered trash receptacle that can be operated without the use of hands, available in each parlor?

_____yes or _____no

14) Are leak resistant bags used to line these trash receptacles? _____yes or _____no

15) Are all instruments/equipment used in the Studio single-use? _____yes or _____no

If answer is yes, do not answer questions 16-26.

16) Are used instruments cleaned and sanitized immediately after use? _____yes or _____no

If answer is yes, do not answer questions 17-18.

17) Are used instruments soaked in an EPA approved disinfectant until cleaning can be performed?

_____yes or _____no

18) What is the name of the disinfectant(s)?

______

19) Are all instruments, prior to sterilization, wrapped or packaged with a sterilizer indicator on each package?

_____yes or _____no

20) Are all packages placed in the sterilizer labeled with the date and time of sterilization?

_____yes or _____no

21) Is the sterilizer designed and labeled as a medical instrument? _____yes or _____no

22) Is a copy of the operator’s manual for the sterilizer available? _____yes or _____no

23) How is the sterilizer cleaned?

______

Please provide an example of the sterilizer log that must be kept for each load. 24) What is the name and address of the company that performs the commercial biological monitoring (spore)

system? ______

______

25) What is the make/model number of the autoclave/sterilizer used in the Body Art Studio?

______

26) Where are all sterilized instruments and equipment stored? ______

______

27) How often are trash receptacles within parlors cleaned?

______

28) What is the name of the company that picks up and disposes of all Biohazard waste materials?

______

And how often do they pick up these wastes?

______

29) Give examples, if any, of what items will be discarded into a non-sharps, bio-hazardous waste

container.______

______

30) How often are regular trash receptacles emptied?

______

31) How often is the commercial dumpster emptied?

______

32) What type of liquid/ sewage waste disposal system is provided for the Studio?

______

33) Where are client records maintained?

______

34) How long are client records maintained?

______35) How are client records discarded after this time period?

______

36) What type of ointment/antibacterial solution(s) are used before, during, and after body art procedures?

______

I understand that approval is based upon the information I have provided within this application, with any documentation, and any drawings I have submitted. I will construct this facility according to these specifications. I also understand that any changes to the information submitted must have prior approval by the health authority before being implemented.

______

Signature of Owner Printed Name of Owner Date