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Application for Individual Tattoo/Body Piercing Artist Certification

  1. letterhead top bar.bmp

  2. Application Fee - $100.00

    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. Instructions

    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. A. YOUR INFORMATION

    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. C. SHOP INFORMATION

    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. IMPORTANT

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

  13. Application Fee $100.00 ~ Make checks payable to: Director of Finance

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

  14. For Office Use Only

    Exam Score ________

  15. Certificate No. __________ Expires: ___________

  16. 3/2014

  17. Certificate Issued?

  18. Date Issued: ___________

  19. Leave This Blank: