Fillable LICENSE APPLICATION FOR TATTOO & BODY PIERCING ESTABLISHMENT (City of South Bend)

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LICENSE APPLICATION FOR TATTOO & BODY PIERCING ESTABLISHMENT (City of South Bend)

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For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
DEFINITION:
A 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 & Body Piercing Artist (Ord. §§13-125 – 13-152)
GENERAL INSTRUCTIONS:
1. Print legibly and complete all sections to ensure efficient processing.
2. Assemble all required information and materials before filing application.
3. Thoroughly review all applicable Municipal Code Sections listed above.
4. Licenses expire January 31.
5. Add $50.00 to the license fee for renewal after January 31.
6. Include $5.00 license application fee payable to City of South Bend.
7. New applicant license fee payable to City of South Bend due at issuance - $250.00, the
renewal license fee is $150.00. (See 13-133 for complete 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 Municipal Code Section 13-
127(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).
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
REQUIRED INFORMATION AND MATERIALS (Continued):
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:
a) Has not met the minimal training and education requirements in order to be
considered for a practitioner's license with the lack thereof being considered an
inability.
b) Has been convicted of a felony.
c) Has been convicted of drug or alcohol violations.
d) Has been determined by a licensed medical physician to be mentally incompetent.
e) Has failed to meet the applicable regulations of this Article.
5. License issued on payment of fee.
6. Permit holder may do business with properly displayed License, and in compliance with
§§13-125 – 13-152.
7. If a license is denied, the applicant may appeal to the Legal Department for a hearing
pursuant to Section 4-16 of this Chapter.
1
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
I. APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA
A. Business Name:
B. Business Address:
City: State: Zip:
C. Mailing Address (If different from above):
City: State: Zip:
D. Business Telephone Number:
E. Business Fax Number:
F. E-Mail Address:
G. Federal Employer Identification Number (EIN):
H. Indiana Taxpayer Identification Number:
I. Zoning of Business Location:
J. 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:
YES NO
1. If yes, what was the reason:
2. Describe the nature and scope of the business operation:
For Office Use Only
Application Filed Police Dept. Approval
Application Fee Paid Fire Dept. Approval
Sent to Dept. Building Dept. Approval
Health Dept. Approval License Fee Paid
License Number
Not Approved
Reason
2
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
III. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City: State: Zip:
2. Partnership (List at least all partners. Attach additional sheets if necessary)
Name #1:
Residential Address:
City: State: Zip:
Name #2:
Residential Address:
City: State: Zip:
3. Corporation
Legal name of corporation:
Date and state of incorporation:
List officers and directors who own 15% or more of stock:
Name #1:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
3
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
III. OWNERSHIP (Continued)
3. Corporation (Continued)
Name #2:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Name #3:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
IV. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City: State: Zip:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. E-Mail Address:
G. Position with business:
H. Please list all criminal convictions (if any), excluding traffic violations:
Nature of Conviction City State Date
(Attach additional sheets if necessary)
4
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
I. Please list all addresses for three (3) years prior to application date:
Street Address City State Dates
(Attach additional sheets if necessary)
J. Date of birth:
K. Gender:
L. Social Security Number:
M. Race:
N. List any other names or aliases by which you have been known:
O. Employment History
Please list all previous employment where services related to this field were rendered:
Company 1:
Dates of Employment:
Address:
City, State, ZIP:
Supervisor:
Telephone Number:
Company 2:
Dates of Employment:
Address:
City, State, ZIP:
Supervisor:
Telephone Number:
5
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTION – 13-125 – 13-152
IV. PERSONAL DATA (Continued)
O. Employment History (Continued)
Company 3:
Dates of Employment:
Address:
City, State, ZIP:
Supervisor:
Telephone Number:
Company 4:
Dates of Employment:
Address:
City, State, ZIP:
Supervisor:
Telephone Number:
(Attach additional sheets if necessary)
V. INCLUDE WITH APPLICATION:
A. Written proof applicant is not a minor.
B. Statement from medical doctor certifying applicant has been examined and found free
of communicable disease within thirty (30) days of application date.
C. Copy of High School Diploma, GED, or degree.
D. 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.
E. 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 the skin and hair
9. Anatomy for piercers
6
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTIONS – 13-125 – 13-152
V. INCLUDE WITH APPLICATION (Continued):
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 manner
Note: Minimum of 600 hours training and education required for Tattoo Establishment
license.
F. 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).
G. Documentation of successful completion of Indiana Occupational Safety and Health
Administration blood borne pathogen standards training program.
H. 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.
I. Diagram of proposed establishment depicting, among other things, locations of all work
stations, restroom facilities, points of ingress/egress, operatory areas, infectious waste
storage areas, and waiting areas.
J. Proposed hours of operation.
K. Proposed schedule of fees, which shall be posted prominently in the establishment.
L. 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.
7
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – TATTOO & BODY PIERCING ESTABLISHMENT
MUNICIPAL CODE SECTIONS – 13-125 – 13-152
V. INCLUDE WITH APPLICATION (Continued):
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.”
M. Copies of proposed pre-service information and aftercare instructions to be used.
N. 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 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 handle infectious waste
in a safe and effective manner.
O. Copy of proposed infectious waste containment policies to be utilized, as well as copy of
proposed policies addressing treatment and transportation of infectious waste.
VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VII. AFFIRMATION
I, hereby, certify and affirm that all of 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.
Signature Date
PLEASE NOTE: Filing of new application for license does NOT authorize conducting Tattoo Artist
Business until such license has actually been issued to applicant.
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LICENSE APPLICATION FOR TATTOO & BODY PIERCING ESTABLISHMENT (City of South Bend)

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Completed 16 July 2020

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