Body Artist Permit Application - Cheyenne Laramie County Public Health

Permit Fee:(Required)

New Applicant: $125

Renewal: $65

Applicant's Full Name(Required)

First Last

Residential Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Date of Birth(Required)

Email Address(Required)

Enter Email Confirm Email

Establishment Name(Required)

Establishment Address(Required)

Street Address Address Line 2 City State ZIP Code

Establishment Phone Number(Required)

BODY ARTIST SIGN OFF LETTER

To be completed and signed by the owner of the Body Art Establishment at which you are employed.

I,(Required)

Owner Name

have employed(Required)

Artist Name

at(Required)

Body Art Establishment Name

If this artist leaves my employment, I agree to notify Cheyenne Laramie County Public Health's Division of Environmental Health immediately.

Owner Signature(Required)

Date(Required)

HEALTH REQUIREMENTS

I,(Required)

Artist

to the best of my knowledge am free of communicable disease.

I,(Required)

Artist

(select one)(Required)

Have been vaccinated for Hepatitis B

Decline vaccination

APPLICANT STATEMENT OF CONSENT

I have received a copy of the Cheyenne-Laramie County Body Art Rules. I have read and understand theobligations and requirements imposed upon a licensed Body Art Practitioner by those regulations. I agree to comply with all of the regulation requirements specified in the Cheyenne-Laramie County Body Art Rules while practicing in Laramie County.

Applicant Signature(Required)

Draw your signature.

Date

Please include the following:

Copy of your Blood Borne Pathogen Training Certificate(Required)

Max. file size: 50 MB.

Copy of your Hepatitis B vaccination record OR a signed and dated letter stating that you’re declining the vaccination and are free of communicable disease(Required)

Max. file size: 50 MB.

Copy of your current driver’s license (with photo)(Required)

Max. file size: 50 MB.

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?(Required)

Yes

If yes, provide the reason:(Required)

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

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)

Date(Required)