Body Art Establishment Plan Review Worksheet NOTE: This plan review will be good for 12 months past the date of submission. After the expiration date, a new plan review and the appropriate fee will need to be resubmitted.Permit Fee:(Required) New: $120 Remodel: $60 Establishment Name(Required) Establishment Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Establishment Phone Number(Required)Fax NumberEmail Address(Required) Enter Email Confirm Email Contact Person(Required) First Last Owner Name(Required) First Last Owner Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Phone Number(Required)Submit the following along with this questionnaire:One complete set of floor plans showing layout of Body Art Establishment(Required)Max. file size: 50 MB.Bloodborne Exposure Control Plan(Required)Max. file size: 50 MB.Copy of the autoclave spore test(Required)Max. file size: 50 MB.Will this establishment be:(Required)PermanentMobileWill work be performed on any patron under the age of 18 years?(Required) Yes No What will be your procedure for verifying legal guardian/parent? TRASH AREAWill each artist area be provided with a covered trash can?(Required) Yes No How will biological/contaminated waste be disposed of?(Required) LIGHTINGWill adequate lighting be provided in each of the procedure rooms?(Required) Yes No WATER AND SEWER SUPPLYWill water supply be from:(Required) City Community Private Well Will sewage be disposed of by:(Required) City Septic System How many hot water heaters will be provided?(Required)What will be the size of the water heaters, in gallons?(Required)How many restrooms will be provided?(Required)Do restrooms have vent fans venting to the outside? Yes No Will restrooms have self-closing doors? Yes No Does the toilet have a split seat? Yes No PROCEDURE ROOMSWhat is the size of each procedure room?(Required) STERILIZATIONWhat is the make and model of the Autoclave?(Required) RECORDSWhere will client records be kept?(Required) FACILITIESFinish schedule - Applicant must fill in materials (i.e. quarry tile, stainless steel, FRP board, etc.)Waiting Area Floor Material(Required) Waiting Area Floor Finish(Required) Waiting Area Floor Cove(Required) Waiting Area Wall Material(Required) Waiting Area Wall Finish(Required) Waiting Area Ceiling Material(Required) Waiting Area Ceiling Finish(Required) Procedure Rooms Floor Material(Required) Procedure Rooms Floor Finish(Required) Procedure Rooms Floor Cove(Required) Procedure Rooms Wall Material(Required) Procedure Rooms Wall Finish(Required) Procedure Rooms Ceiling Material(Required) Procedure Rooms Ceiling Finish(Required) Storage Area Floor Material(Required) Storage Area Floor Finish(Required) Storage Area Floor Cove(Required) Storage Area Wall Material(Required) Storage Area Wall Finish(Required) Storage Area Ceiling Material(Required) Storage Area Ceiling Finish(Required) Cleaning Room Floor Material(Required) Cleaning Room Floor Finish(Required) Cleaning Room Floor Cove(Required) Cleaning Room Wall Material(Required) Cleaning Room Wall Finish(Required) Cleaning Room Ceiling Material(Required) Cleaning Room Ceiling Finish(Required) Restroom Floor Material(Required) Restroom Floor Finish(Required) Restroom Floor Cove(Required) Restroom Wall Material(Required) Restroom Wall Finish(Required) Restroom Ceiling Material(Required) Restroom Ceiling Finish(Required) Garbage & Refuse Area Floor Material(Required) Garbage & Refuse Area Floor Finish(Required) Garbage & Refuse Area Floor Cove(Required) Garbage & Refuse Area Wall Material(Required) Garbage & Refuse Area Wall Finish(Required) Garbage & Refuse Area Ceiling Material Garbage & Refuse Area Ceiling Finish PLUMBINGNumber of Procedure Room Hand Sinks(Required)Location of Procedure Room Hand Sinks(Required) Number of Bathroom Hand Sinks(Required)Location of Bathroom Hand Sinks(Required) Number of Mop Sinks(Required)Location of Mop Sink(s)(Required) Number of Equipment Cleaning Sinks(Required)Location of Equipment Cleaning Sink(s)(Required) Δ