Guest Tattoo/Body Piercing Artist 7-67 Food & Consumer Protection
SS Updated 10/30/2019 MRW-MRH 16 Allen County Dept. of Health
200 E. Berry Street Suite 360 Fort Wayne, IN 46802
www.allencountyhealth.com
PERMIT APPLICATION FOR A
GUEST TATTOO/BODY PIERCING ARTIST
Issuance of a guest tattoo/body piercing artist is dependent upon providing documentation of Bloodborne Pathogen Certification meeting
OSHA Standard as described in 29 CFR 1910.1030. Applications received with incomplete information will not be processed.
Name of Artist
Artist Home Address
Street City State Zip Code
Artist Telephone Artist Email
Guest Facility Name Guest Facility Owner
Guest Facility Address
Street City State Zip Code
Guest Facility Phone Guest Facility Fax or Email
Please check the services you are requesting licensure for: Tattooing Body Piercing Both
All artists shall comply with minimum training requirements as required in Allen County Code Title 10 Article 7.
I, , hereby apply for a permit to practice as a Guest Tattoo Artist, Guest Body Piercing
Artist, or Both (as stated above) in a permitted Tattoo/Body Piercing Establishment in Allen County, Indiana. I also agree to strictly
follow all of Allen County and the State of Indiana code(s), laws and regulations regarding the operation(s) of a Tattoo/Body Piercing
Establishments.
Tattoo Artist and Body Piercer Responsibilities/Requirements state that each artist must provide documentation of the following
information to the Allen County Department of Health. This documentation must also be on file at the licensed Tattoo/Body Piercing
Establishment and available for inspection upon request. All applicable corresponding documentation below must be submitted with
this permit application. Check the box which applies to you:
I have completed the Hepatitis B vaccination series (and am submitting shot record/date verification)
I have been offered, and declined, in writing, the Hepatitis B vaccination series (declination form required)
I have not completed the Hepatitis B vaccination series but am providing documentation showing at least the first of the
series of has been received and will show proof of completion of the series within six (6) months of issue of this permit
Make all checks or money orders payable to: Allen County Department of Health
By signing below, I am agreeing to all conditions listed herein and verify the information provided is accurate.
_____________________________________________ ________________
Signature of Applicant Date
--------------------------------------------------------------------------- OFFICE USE ONLY------------------------------------------------------------------------------------------
Artist Verified with Facility (date & initials) _________________________
Permit Number
Date Entered
Guest Tattoo Artist or Body Piercer $35.00 (30-day permit)
NOTE: Payments made by check that result in non-sufficient funds will result in the requirement for immediate payment to the Allen County
Department of Health (plus an additional NSF check fee) via cash, money order or certified check within 24 business hours.
If payment is not received within 24 business hours of notification, the establishment will be closed until fees are paid in
full.
Any and all charges for services and permits are your sole responsibility and are to be paid in full upon application.
In the event any legal proceeding must be instituted to recover the amount due, the Allen County Department of Health
shall be entitled to recover the cost of the collections, including reasonable attorney fees.
Fort Wayne Tattoo Festival
120 W Jefferson Blvd, Fort Wayne, IN 46802
click to sign
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