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2. Verified by
3. Total Fee
4. Receipt No.
5. Date Paid
   Date Paid
7. SR Number
8. This plan checklist is provided as a guidance document to assist the facility owner/operator to open a Body Art Facility that will meet public health and safety requirements established by California’s Safe Body Art Act (AB300). The applicant must complete all parts prior to providing services to the public.
10. Name of Business
11. Address of Business
13. City
14. State
15. Zip Code
17. Facility Owner Name
18. Phone
19. Number of Stations / Procedure Areas
21. Facility Square Footage
22. Type of Body Art Facility
    List All Services Performed (e.g. Piercing, Tattooing, Permanent Cosmetics, or Branding)
24. Contact for Plans:
    Name
25. 
    Title
27. Phone
28. Email
29. Fax
31. Billing Information
    Name
32. 
    Address
34. City, State, Zip
35. Phone
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field