<p> Brenda Fitzgerald, MD, Commissioner | Nathan Deal, Governor</p><p>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</p><p>Body Art Studio Application</p><p>_____ New Application _____ Re-location _____Renovation</p><p>Type of Procedures _____Tattoo _____Piercing _____Other (please explain) </p><p>Comments:______</p><p>______</p><p>Body Art Studio Information</p><p>Full/Legal Name of Body Art Studio:______</p><p>Body Art Studio Address:______</p><p>City:______, GA Zip:______</p><p>Phone:______Fax:______</p><p>Days of Operation: (circle all that apply): S M T W Th F Sat Hours of Operation: ______</p><p>Appointment Only: Body Art Studio Owner Information Type of Ownership: ____Sole Proprietor _____Partnership _____Corporation _____Other</p><p>Owner’s Name(s): ______</p><p>Owner’s Address(es): ______</p><p>City:______, GA Zip:______</p><p>Phone:______Alternative Phone: ______</p><p>Email:______</p><p>*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.</p><p>Please provide the following with your completed application:</p><p>_____ A list containing the full names and home address of all employees and staff who will be working in the Body Art Studio.</p><p>_____ A copy of client informed consent statement and disclaimer of liability. </p><p>_____ A copy of after-care procedures form.</p><p>_____ 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.</p><p>_____ Contact appropriate jurisdictions and comply with each jurisdictions applicable codes and requirements.</p><p>_____ A copy of the Certificate of Occupancy for the Body Art Studio.</p><p>_____ Pay applicable permit fees.</p><p>_____ Specifications on autoclave equipment or written statement that instruments used are all single-use</p><p>_____ 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.</p><p>_____ If the Studio performs body piercing, please provide manufacturer’s specification on all jewelry.</p><p>_____Written emergency plan in the event the primary autoclave/sterilizer malfunctions or tests positive for spores. </p><p>_____Review O.C.G.A Rules referencing Body Art </p><p>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.</p><p>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.</p><p>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. </p><p>Signature: ______Date______</p><p>1) Does your equipment sink meet NSF (National Safety Foundation) Standards? _____yes or _____no</p><p>2) Are all furnishings of the Body Art Studio intact and functional? _____yes or _____no</p><p>3) Are cabinets for the storage of instruments, pigments, single- use articles, carbon, stencils, jewelry, studs, and </p><p> other supplies provided for each Body Artist? _____yes or _____no</p><p>4) Of what material are these cabinets made? </p><p>______</p><p>5) Are all surfaces of work tables, chairs, and furnishings constructed of material that is smooth, non-absorbent, </p><p> easily cleanable, and corrosion resistant? _____yes or _____no</p><p>6) What solution/chemical is used to sanitize furnishings after each procedure? </p><p>______</p><p>______</p><p>7) Is there a separate, designated area for eating and drinking for employees and customers? </p><p>_____yes or _____no </p><p>If yes, please explain______</p><p>______</p><p>8) Where are single-use, sterile supplies stored? </p><p>______</p><p>______9) Does this Studio perform Body Piercing? _____yes or _____no</p><p>10) Is all gauze used for procedures single-use and sterile? _____yes or _____no</p><p>11) How is antibacterial ointment dispensed for each procedure? </p><p>______</p><p>______</p><p>12) Are dyes and pigments dispensed into single-use containers? _____yes or _____no</p><p>13) Is a covered trash receptacle that can be operated without the use of hands, available in each parlor? </p><p>_____yes or _____no</p><p>14) Are leak resistant bags used to line these trash receptacles? _____yes or _____no</p><p>15) Are all instruments/equipment used in the Studio single-use? _____yes or _____no</p><p>If answer is yes, do not answer questions 16-26. </p><p>16) Are used instruments cleaned and sanitized immediately after use? _____yes or _____no</p><p>If answer is yes, do not answer questions 17-18.</p><p>17) Are used instruments soaked in an EPA approved disinfectant until cleaning can be performed? </p><p>_____yes or _____no</p><p>18) What is the name of the disinfectant(s)? </p><p>______</p><p>19) Are all instruments, prior to sterilization, wrapped or packaged with a sterilizer indicator on each package? </p><p>_____yes or _____no</p><p>20) Are all packages placed in the sterilizer labeled with the date and time of sterilization? </p><p>_____yes or _____no</p><p>21) Is the sterilizer designed and labeled as a medical instrument? _____yes or _____no</p><p>22) Is a copy of the operator’s manual for the sterilizer available? _____yes or _____no</p><p>23) How is the sterilizer cleaned? </p><p>______</p><p>______</p><p>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) </p><p> system? ______</p><p>______</p><p>25) What is the make/model number of the autoclave/sterilizer used in the Body Art Studio? </p><p>______</p><p>26) Where are all sterilized instruments and equipment stored? ______</p><p>______</p><p>27) How often are trash receptacles within parlors cleaned? </p><p>______</p><p>28) What is the name of the company that picks up and disposes of all Biohazard waste materials? </p><p>______</p><p>______</p><p>And how often do they pick up these wastes? </p><p>______</p><p>29) Give examples, if any, of what items will be discarded into a non-sharps, bio-hazardous waste </p><p> container.______</p><p>______</p><p>30) How often are regular trash receptacles emptied? </p><p>______</p><p>31) How often is the commercial dumpster emptied? </p><p>______</p><p>32) What type of liquid/ sewage waste disposal system is provided for the Studio? </p><p>______</p><p>33) Where are client records maintained? </p><p>______</p><p>34) How long are client records maintained? </p><p>______35) How are client records discarded after this time period? </p><p>______</p><p>36) What type of ointment/antibacterial solution(s) are used before, during, and after body art procedures? </p><p>______</p><p>______</p><p>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.</p><p>______</p><p>Signature of Owner Printed Name of Owner Date</p>