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Application for Individual Tattoo/Body Piercing Artist Certification

  1. letterhead top bar.bmp

  2. Practice of tattooing or body piercing shop without certification is a violation of Article XIII of the Sanitary Code of the Chautauqua County Health District.

  3. Submit at least 30 days prior to first day of operation or at least 15 days prior to the expiration of a current certification. False statements on this application may be cause for certification revocation.

  4. Application Type*

  5. PLEASE NOTE: You must obtain a waiver (Form C-105.21) from the NYS WCB Showing that you are not required to carry workers' compensation and disability benefits coverage

  6. Sex*

  7. B. PROCEDURES TO BE PERFORMED BY APPLICANT*

  8. Indicate the shop where you are currently employed:

  9. For above shop you are*

  10. If employed at a second shop, please provide shop name and address:

  11. The applicant hereby agrees that the information provided herein is accurate.

  12. THE APPLICANT MUST SUBMIT A PASSPORT IDENTIFICATION PICTURE WITH THIS COMPLETED APPLICATION FORM.

  13. CCDOH, Environmental Div, HRC Building, 7 North Erie Street, Mayville, NY 14757

  14. Exam Score ________

  15. Certificate Issued?

  16. Leave This Blank: