Tattoo and Body Piercing Establishment License

License Application for - Tattoo & Body Piercing Establishment

MUNICIPAL CODE SECTION – 13-125 to 152
South Bend Municipal Code: Section 13-125 to 152

Definition

Tattoo Establishment refers to all places of business and all areas used by tattoo and piercing practitioners. This primarily includes the facility treatment area, waiting/reception area, and premises.

IF DESCRIPTION DOES NOT APPLY, SEE:
Tattoo and Body Piercing Artist (Ord. §§13-125 – 13-152)

General Instructions:
1. Assemble all required information and materials before filing application.
2. Thoroughly review all applicable Municipal Code Sections listed above.
3. Licenses expire on the January 31.
4. Add $50 to license fee for renewal after January 31.
5. Include $5.00 license application fee payable to City of South Bend. You may pay this in-person at City Hall, or call the Business Licensing Manager at 574-235-5912 to pay over the phone.
6. License fee payable to City of South Bend due at issuance - $250. Renewal applicant license fee is $150.00. See 13-133 for full schedule of fees.
Required Information and Materials:
1. Business Entity information, if applicable.
2. Proposed location where services to be provided, and description of services.
3. Copy of diploma, GED, or degree.
4. Transcript(s) outlining all training and qualifications (see 13-126(a)(7)).
5. Work history and professional associations and memberships.
6. Criminal history.
7. Documentation of completion of Indiana Occupational Safety and Health Administration's blood borne pathogen standards training.
8. Documentation of compliance with all applicable infectious waste handling guidelines, policies, and regulations.
9. Doctor’s written certification applicant has been examined and found free of all communicable disease within thirty (30) days of application.
10. Copy of liability insurance policy, as required.
11. Personal and professional data on all employees providing services, per Municipal Code Section 13-127(a)(11).
12. Diagram of proposed facility, per Municipal Code Section 13-127(a)(15).
13. Proposed hours of operation and fees to be charged for services, as will be posted on premises.
14. Proposed pre-service information and aftercare instructions to be used.
15. Proposed written policies to be used, in compliance with Municipal Code Sections 13-125 – 13-152 and Indiana Occupational Safety and Health Administration's blood borne pathogens standards. See Municipal Code Section 13-127(a)(20).
APPLICATION PROCESS:
1. Review Municipal Code Sections 13-125 – 13-152 thoroughly.
2. Submit Application with $5.00 Processing Fee.
3. Health, Building, Fire and Police Department review and recommendations.
4. No applicant for a practitioner's license shall be issued such license if he or she:
  1. Has not met the minimal training and education requirements to be considered for a practitioner's license with the lack thereof being considered an inability.
  2. Has been convicted of drug or alcohol violations.
  3. Has been determined by a licensed medical physician to be mentally incompetent.
  4. Has failed to meet the applicable regulations of this Article.
5. License issued upon approval and payment of the license fee.
6. Permit holder may do business with properly displayed License, and in compliance with §§13-125 – 13-152.
7. Tattoo & Body Piercing Establishment license required per §§13-125 – 13-152 for locations where services to be provided.
8. If a license is denied, the applicant may appeal to the Mayor for a hearing pursuant to Section 4-16 of this Chapter.

Application Type
Is this application pertaining to a new business or are you renewing your existing permit?*

New PermitRenew Permit
Business Data
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does Mailing address differ from Property Address?*

Yes, different addressNo, Same address
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email Address*
example@example.com
Federal Employer Identification Number (EIN)
Indiana Taxpayer Identification Number
Zoning of Business Location
To find your business location's zoning type, use the South Bend Zoning Map.
Have you ever had a tattoo/piercing establishment license, or similar license, suspended or revoked by any governing municipality within three (3) years prior to the date of this application?

YesNo
if yes, what was the reason?
Describe the nature and scope of the business
Proposed Hours of Operation
Include days of week and hours
Ownership
Type of ownership

Sole ProprietorshipPartnershipCorporation
Owner's Legal Name*

First NameMiddle NameLast Name
Owner's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner 1's Legal Name*

First NameMiddle NameLast Name
Partner 1's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner 2's Legal Name*

First NameMiddle NameLast Name
Partner 2's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Name of Corporation
State of Corporation
Date of Corporation

MonthDayYear
List officers and directors who own 15% or more stock. Include name, title, business address, and residential address.
Personal Data
Applicant's Legal Name*

First NameMiddle NameLast Name
Applicant's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email*
example@example.com
Applicant's Position with Business

Please list all criminal convictions (if any), excluding traffic violations

Rows	Nature of Conviction	City	State	Date
Conviction 1
Conviction 2
Conviction 3
Conviction 4

Add more information if necessary

Please list all addresses for three (3) years prior to application date

Rows	Street Address	City	State	Dates
Address 1
Address 2
Address 3
Address 4

Add more addresses if necessary

Please list all employers for three (3) years prior to application date

Rows	Street Address	City, State, Zip	Dates	Company Name
Company 1
Company 2
Company 3
Company 4

Add more employers if necessary
Last four digits of Applicant's Social Security Number*
Upload a picture of Applicant's Driver's License or other government issued ID

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Applicant's Gender*
Applicant's Race*
Applicant's Date of Birth*

MonthDayYear
Written Proof Applicant is not a minor

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Statement from medical doctor certifying applicant has been examined and found free of communicable disease within thirty (30) days of application date

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Copy of High School Diploma, GED, or degree.

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List of all training and education pursuant to work and services to be provided, including name and address of institution attended, dates of attendance, degrees or certifications earned, and credit hours completed.

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Please attach below an official transcript showing training and education, including practical theory for the following:
1. Laws and rules
2. Bacteriology
3. Sanitation and sterilization
4. Anatomy and physiology
5. Endocrinology
6. Equipment/supplies
7. Basic color theory / pigments
8. Structure, dynamics, and diseases of skin and hair
9. Anatomy for piercers
10. Insurance
11. Circulatory and nervous systems
12. Draping and positioning
13. Professional ethics and business
14. Needles
15. Tattoo machines
16. Safety, sanitization, and sterilization
17. Skin diseases, disorders, and conditions
18. Client handling
19. Body piercing techniques
20. CPR
21. Piercing and bedside manners
Note: Minimum of 600 hours training and education required for Tattoo Establishment License.
Attach Official Transcript

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List of all current memberships, lengths of membership, and membership numbers in associations and organizations addressing services regulated by §§13-125 – 13-152 including but not limited to such organizations as The Association of Professional Piercers (APP), The Alliance of Professional Tattooists (APT), and the Society of Permanent Cosmetic Professionals (SPCP).

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Documentation of successful completion of Indiana Occupational Safety and Health Administration blood borne pathogen standards training program.

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Below, please provide a list of all persons to provide services at proposed establishment, including name, address, telephone number and Practioner’s License number for each. In addition, verify each person:
1. Has met the minimal training requirements in order to be considered for a Tattoo Establishment License, with the lack thereof to be considered an inability.
2. Has not been convicted of a felony.
3. Is not a known drug user or alcohol abuser.
4. Has not been determined by a licensed physician to be mentally incompetent.
List of persons to provide services at proposed establishment

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Diagram of proposed establishment depicting, among other things, locations of all workstations, restroom facilities, points of ingress/egress, operatory areas, infectious waste storage areas, and waiting areas.

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Proposed schedule of fees, which shall be posted prominently in the establishment.

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Certificate of Insurance verifying: (1) $500,000 minimum liability insurance coverage for injury as a result of any one occurrence. (2) $1,000,000 minimum public liability insurance coverage for accidental bodily injury, including death, to any member of the public as a result of any one occurrence. Insurance policy to contain the following provision: “The City of South Bend, through the Office of the City Controller, will be given fifteen (15) business days’ notice prior to the effective date of cancellation or other material change to this policy.”

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Copies of proposed pre-service information and aftercare instructions to be used.

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Please provide proposed written policies to be used, in compliance with Municipal Code Sections 13-125 – 13-152 and Indiana Occupational Safety and Health Administration's blood born pathogens standard that:
1. Require the use of universal precautions when performing any service
  regulated by Article 13 that includes any reasonably anticipated skin, eye,
  mucous membrane or parental contact with blood or OPIM.
2. Includes the safe and effective handling of infectious waste; and,
3. Provides sanctions, including discipline and dismissal, if warranted, for any employee who fails to use universal precautions and/or handles infectious
  waste in a safe and effective manner.
Written Health and Safety Policies

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Copy of proposed infectious waste containment policies to be utilized, as well as copy of proposed policies addressing treatment and transportation of infectious waste.

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Signature
I, hereby, certify and affirm that all the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I agree to cooperate with any review conducted pursuant to the licensing procedures, including permission to enter and inspect the place of business and facilities in conjunction with such a review. I have read and understand the regulations Tattoo Establishments and Technicians found in the City of South Bend Municipal Code, Sections 13-125 – 13-152.
Electronic Signature*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

License Application for - Tattoo & Body Piercing Establishment

Definition

General Instructions:

Required Information and Materials:

APPLICATION PROCESS:

Application Type

Business Data

Ownership

Personal Data

Signature