|Application to Operate a Tattoo and/or Body Piercing Establishment
Approval Valid May 1, 2010 – April 30, 2011
Complete the applicable sections. Make any corrections if necessary.
Sign and date the application.
Make a check or money order payable to: Sidney-Shelby County Health Department
Return check of $325.00 and signed application by: April 30, 2010
to: Sidney-Shelby County Health Department
202 W. Poplar Street, Sidney, Ohio 45365
TYPE OF OPERATION:
Tattooing Body Piercing Tattooing & Body Piercing
Name of Tattoo and/or Body Piercing Business: Tax ID#:
Phone Number: ( )
Name of Operator: SS#:
City State Zip Code
Daytime Office Phone Number: ( )
Home Phone Number: ( )
Days of Operation: Hours of Operation:
I HEREBY CERTIFY THAT I AM THE OPERATOR, OR THE AUTHORIZED REPRESENTATIVE OF THE ABOVE OPERATION AND INTEND TO COMPLY WITH ALL REQUIREMENTS ESTABLISHED BY SECTION 3730 OF THE OHIO REVISED CODE AND SECTION 3701 OF THE OHIO ADMINISTRATIVE CODE.
FOR OFFICE USE ONLY:
Approval No.: Issued on: