APPLICATION FOR PERMIT TO OPERATE A BODY ART ESTABLISHMENT

SECTION A:	IDENTIFICATION – Please print legibly in all blocks below, except where signature is required.   

1.  NAME AND LOCATION OF BODY ART ESTABLISHMENT    (Enter Street Address.  Do Not Use P.O. Box Numbers)






TEL NO. OF ESTABLISHMENT:  _________  --  _________  --  _______________             

FAX NO.  _________  --  _________  --  _______________  


2.  NAME AND PERMANENT MAILING ADDRESS OF APPLICANT  		3.  SEASONAL/TEMPORARY ADDRESS (IF APPLICABLE)






TEL NO. _________  --  _________  --  _______________  		TEL NO. _________  --  _________  --  _______________ 


4.  MAIL CORRESPONDENCE TO (CHECK ONE):     __ ADDRESS SHOWN IN BLOCK #A1     __ ADDRESS SHOWN IN BLOCK #A2



SECTION B:	TYPE OF ESTABLISHMENT       ___ NEW ESTABLISHMENT             ___ RENEWAL

(CHECK ONLY ONE CLASSIFICATION BELOW) 

     	1. __ FIXED LOCATION - PERMANENT STRUCTURE LOCATED AT ADDRESS SHOWN IN BLOCK #A1 ABOVE.	 	

     	2. __ MOBILE UNIT - (SPECIFY ADDRESS WHERE UNIT IS MAINTAINED___________________________________)

-   	IF THIS IS A CHANGE OF OWNERSHIP, INDICATE THE PREVIOUS ESTABLISHMENT NAME AND BUSINESS ID, IF KNOWN.
    	
	PREVIOUS NAME:  ______________________________________________  PREVIOUS BUSINESS ID:  __________________
	
TYPE OF PERMIT REQUESTED	(CHECK ONLY ONE CLASSIFICATION BELOW) 

     1.  __ PERMANENT  - PROVIDES FULL SERVICES.	ANNUAL RENEWAL IS REQUIRED.	PERMIT FEE IS $100.00.
     2.  __ RESTRICTED - PROVIDES LIMITED SERVICES.     ANNUAL RENEWAL IS REQUIRED.	PERMIT FEE IS $100.00.	
     3.  __ TEMPORARY  - VALID FOR A PERIOD NOT TO EXCEED 14 CONSECUTIVE DAYS.		NO FEE IS CHARGED.	

TYPE OF BUSINESS ENTITY		(CHECK ONLY ONE CLASSIFICATION BELOW)
     1. __ INDIVIDUAL					2. __ PARTNERSHIP  (NAME:  ______________________________)
     3. __ ASSOCIATION  (NAME:  _____________________)	4. __ CORPORATION (NAME:  _______________________________)
     5. __ OTHER ENTITY (SPECIFY TYPE: __________________________________________________________________________)

FEES:	PLAN REVIEW IS REQUIRED FOR NEW CONSTRUCTION, CONVERSION OF EXISTING STRUCTURE TO BODY ART  
	ESTABLISHMENT USE, REMODELING, RENOVATION, OR CHANGES IN ESTABLISHMENT TYPE.	NO FEE IS CHARGED.

ESTABLISHMENT PERMIT FEE IS DUE WHEN THE BODY ART ESTABLISHMENT IS INSPECTED AND APPROVED 
FOR OPERATION.  UPON APPROVAL, AN INVOICE WILL BE SENT TO THE APPLICANT OF RECORD.  THE 
ANNUAL PERMIT FEE OF $100.00 IS PAYABLE TO “DIVISION OF PUBLIC HEALTH” UPON INVOICING.

SECTION C:	CERTIFICATION STATEMENT  (APPLICANT SIGNATURE IS REQUIRED BELOW.  DO NOT PRINT)

I, THE UNDERSIGNED, IN APPLYING FOR A BODY ART ESTABLISHMENT PERMIT, ATTEST TO THE ACCURACY OF THE 
INFORMATION PROVIDED IN THIS APPLICATION.  I  AFFIRM THAT THE ESTABLISHMENT WILL BE OPERATED IN 
COMPLIANCE WITH APPLICABLE “STATE OF DELAWARE REGULATIONS GOVERNING BODY ART ESTABLISHMENTS” AND 
WILL ALLOW AUTHORIZED REPRESENTATIVES OF THE DIVISION OF PUBLIC HEALTH ACCESS TO THE ESTABLISHMENT 
AND ITS RECORDS, AS MAY BE REQUIRED BY APPLICABLE REGULATIONS.



APPLICANT SIGNATURE  ______________________________      DATE  _______ / _______ / ________

FOR OFFICIAL USE ONLY BELOW THIS LINE

APPLICATION REVIEWED:  APPROVED_____   DISAPPROVED_____   BY________________________ DATE ___ / ___ / _____	

Doc. #35-05-20/06/08/17