Richland Public Health
555 Lexington Ave., Mansfield, OH 44907
419-774-4500 • www.richlandhealth.org

2021 APPLICATION TO OPERATE A TATTOO AND/OR 
BODY PIERCING ESTABLISHMENT

INSTRUCTIONS:
Complete all applicable sections.  Make any corrections as necessary, and sign and date the application. Make check or money order in the amount of $385.00 payable to:	
						
						Richland Public Health
						555 Lexington Avenue
						Mansfield, OH  44907

IF YOU ARE RENEWING YOUR LICENSE, PAYMENT MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31, 2020 OR A 25% LATE PENALTY WILL BE ADDED.

TYPE OF OPERATION:					ARTIST NAME(S):
	_____ Tattooing Services			____________________________________
	_____ Body Piercing Services		             ____________________________________	
             _____ Combined Body Art Services 		____________________________________
								Add additional artists on back of application
BUSINESS INFORMATION:
	Name of Operation: _______________________________________________________
	Address: ________________________________________________________________
	City: _________________________		State: ___________	Zip: ______________
	Phone Number for Operation: ________________________________

OWNER/OPERATOR INFORMATION:
	Name of All Owner/Operator (s) with five (5) % or more interest in the business: 	________________________________________________________________________
	________________________________________________________________________	________________________________________________________________________
	Address (if different from above): ____________________________________________
	City: __________________________	State: __________	Zip: ______________
	Daytime Phone Number(s): ______________________________
					         ______________________________
	Days of Operation (circle): 	M	T	W	Th	F	Sat	Sun
	Hours of Operation: _______________________________________________________

I HEREBY CERTIFY THAT I AM THE OPERATOR, OR THE AUTHORIZED REPRESENTATIVE OF THE ABOVE OPERATION AND WILL COMPLY WITH ALL REQUIREMENTS ESTABLISHED UNDER SECTION 3730 OF THE OHIO REVISED CODE AND SECTION 3701 OF THE OHIO ADMINISTRATIVE CODE.

Signature: _____________________________________________	 Date: __________________	

DO NOT WRITE BELOW THIS LINE
Approved by: __________________________________________     Date:_________________

   Prevent. Promote. Protect.