Form Dh 4147 PDF Details

The DH 4147 form is an essential document issued by the State of Florida Department of Health, playing a crucial role for individuals aiming to practice tattooing within the state. As an application for a Tattoo Artist License, it embodies a comprehensive framework that ensures the artist meets the required standards for safety and health protocols. Applicants are guided not to leave any section blank, with instructions to mark "NA" for items that do not apply, ensuring a fully completed submission. The form is structured to accommodate both initial licensing and renewal requests, directing applicants to submit it to the county health department responsible for the tattooing program in their residing area. Moreover, the form outlines necessary attachments such as the license fee, a government-issued photo ID for new applicants, and a certificate from an approved blood-borne pathogens and communicable diseases course, underscoring the seriousness with which Florida addresses public health in the tattoo industry. It also requires applicants to provide information about the establishment(s) where they plan to work, further aligning with the state's commitment to impeccably maintained sanitary conditions in tattoo facilities. By agreeing to the terms on the form, applicants commit to adhering to Florida's health and safety statutes and regulations, underlining the legal and ethical responsibilities of becoming a licensed tattoo artist in the state.

QuestionAnswer
Form NameForm Dh 4147
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesE-mail, Licensee, fl application tattoo form, revocation

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DH use only: Check No.

 

Check Amount

 

 

Date Received

 

Receipt No.

 

 

Facility Permit No.

 

Date Issued

 

 

Amended Application Only

Date Received

 

 

 

 

 

 

 

 

 

 

 

 

STATE OF FLORIDA

DEPARTMENT OF HEALTH

Authority 381.00775, Florida Statutes

Application for Tattoo Artist License

Instructions: Do not leave any item blank. Enter “NA” for non-applicable items. For initial license and license renewal, submit the completed application to the county health department that has jurisdiction for the tattooing program in the county where the applicant lives. To select the county, type the following link into Internet browser: http://www.myfloridaeh.com/community/biomedical/county_coordinators.htm. This application must be accompanied by the following:

Fee of $60.00 (submit every year).

Reactivation fee of $25.00 for renewal of license after date of expiration.

A copy of a government-issued photo identification confirming at least 18 years of age (submit for initial registration only, not renewal).

A copy of the certificate of training proving completion of a department approved course on blood-borne pathogens and communicable diseases with having achieved a minimum score of at least 70% on the course examination (submit for initial application only, not renewal).

Type of License: ____ Initial ____ Renewal

Name of Applicant: ______________________________________________________________________________

Physical Address of Applicant: ______________________________________________________________________

StreetCityStateZip Code

Mailing Address if Different: ________________________________________________________________________

P.O. Box or StreetCityStateZip Code

Phone Number: _(____)__________________ E-mail Address: _____________________________@___________________

Provide the following information for each tattoo establishment or temporary tattoo establishment where the applicant will perform tattooing or intends to perform tattooing:

1.

___________________________________________________________________________________________

 

Name of Licensed Establishment

Department of Health License Number

2.

___________________________________________________________________________________________

 

Name of Licensed Establishment

Department of Health License Number

3.

___________________________________________________________________________________________

 

Name of Licensed Establishment

Department of Health License Number

The undersigned Applicant hereby agrees to practice tattooing in compliance with ss. 381.00771-381.00791, F.S., and Chapter 64E-28, F.A.C., and exclusively at an establishment licensed under ss. 381.00771-381.00791, F.S., and

Chapter 64E-28, F.A.C. The information contained in this application, which serves as a basis for licensure, is true and correct. I understand that any misrepresentation of the facts in this application, or failure to comply with sanitary standards, is grounds for denial, administrative fine and/ or revocation of the tattoo license. Further, I understand that obtaining or attempting to obtain a license or registration by means of fraud, misrepresentation, or concealment is committing a misdemeanor of the second degree punishable as provided in s. 775.082 or s. 775.083.

_______________________________________________________

___________________________

Name of Applicant (print or type)

Date

_______________________________________________________

 

Signature of Applicant

 

DH 4147, 8/12

64E-28.003, F.A.C.