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3. SR Number
4. 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.
6. Name of Business
7. Address of Business
9. City
10. State
11. Zip Code
13. Facility Owner Name
14. Phone
15. Number of Stations / Procedure Areas
17. Facility Square Footage
18. Type of Body Art Facility
    List All Services Performed (e.g. Piercing, Tattooing, Permanent Cosmetics, or Branding)
20. Contact for Plans:
    Name
21. 
    Title
23. Phone
24. Email
25. Fax
27. Billing Information
    Name
28. 
    Address
30. City, State, Zip
31. Phone
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field