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Application to Operate a Tattoo and/or Body Piercing Establishment

Approval Valid May 1, 2010 – April 30, 2011
INSTRUCTIONS:


  1. Complete the applicable sections. Make any corrections if necessary.

  2. Sign and date the application.

  3. Make a check or money order payable to: Sidney-Shelby County Health Department



  4. 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
BUSINESS INFORMATION:
Name of Tattoo and/or Body Piercing Business: Tax ID#:

Address:


Street



City State Zip Code


Phone Number: ( )
OPERATOR INFORMATION:
Name of Operator: SS#:

Address:


Street



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.
Signed: Date:

FOR OFFICE USE ONLY:


Approval No.: Issued on:


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