Body Art Special Event Application - Cheyenne Laramie County Public Health

$125 permit fee. Submit application 30 days prior to event. Maximum 7 consecutive days per event.

Licensed Body Art Establishment:(Required)

Establishment Manager’s Full Name:(Required)

First Last

Event Name:(Required)

Event Start Date:(Required)

Event End Date:(Required)

Event Address:(Required)

Street Address Address Line 2 City State ZIP Code

Manager’s Phone Number:(Required)

Driver’s License State and Number:(Required)

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email:(Required)

Enter Email Confirm Email

List full names of all event artists:(Required)

Are you operating in the county?(Required)

Yes

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

If yes, provide reason:(Required)

Have you ever been convicted of any crime other than a misdemeanor traffic offense?(Required)

Yes

If yes, If yes, provide date, nature and location of offense:(Required)

AUTHORIZATION TO REQUEST/RELEASE INFORMATION

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 the 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)