Body Art Establishment Permit Application

Company

This field is for validation purposes and should be left unchanged.

Fee:(Required)

New Applicant: $125

Renewal: $65

Applicant's Full Name:(Required)

First Last

Date of Birth:(Required)

Residential Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Email Address:(Required)

Enter Email Confirm Email

Establishment Name:(Required)

Establishment Address:(Required)

Street Address City State ZIP Code

Establishment Phone Number:(Required)

List Full Names and Permit Numbers of All Employed Artists:(Required)

Full Name:

Permit Number:

To add more names and permit numbers, click the plus (+).

*FILL OUT BELOW ONLY IF YOU ARE OPERATING IN LARAMIE COUNTY*

NOTICE: Failure to fully disclose all information requested may be grounds for denial of a license or permit, or subsequent suspension or revocation.

Have you ever had a business license or permit denied, revoked or suspended?

YES

Provide reason:

Have you, or any officer, stockholder, shareholder or partner if the applicant is a business entity, ever been convicted of any crime other than a misdemeanor traffic offense?

YES

Provide name of individual, date, nature and location of offense:

The undersigned applicant hereby authorizes Cheyenne Laramie County Public Health and its agents and employees to seek information and conduct investigations to verify the information in this application, including criminal history record act information from the Laramie County Sheriff. I further authorize the Laramie County Sheriff to release information obtained through such background investigation to authorized personnel at Cheyenne Laramie County Public Health. I further agree to comply fully with the rules and regulations of Cheyenne Laramie County Board of Health governing the permit requested, and declare that the information contained in this application is true and correct.

Applicant's Signature:(Required)

Draw your signature.

Date(Required)