Form Dh 4147 – Fill Out and Use This PDF

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.