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Establishment Details
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(Temporary Food Only) Type the Event. If not listed, type the details in the "Temporary Food" section.
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{[CNAME]}
{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[PPHONE]}
{[AWEBSITE]}
{[CNAME]}
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Complete the details in each section below to complete your application. *
Establishment License Application
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  • Contacts
  • Body Art/Permanent Cosmetics
  • Body Art/Tattoo Form EHS-35
  • Body Art/Tattoo Checklist
  • Cafeteria
  • Camps
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  • Fowl
  • Mobile Food
  • Public Bathing
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Person in Charge Details
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Provide details of the person in charge of the establishment/operation
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If the establishment is owned by a corporation, please complete this section.
Corporation Name
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Provide details of a contact person for the business after business hours in the event of an emergency.
First Name
Name
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Address
Check this box if you would like the mailing address to be corporate
Phone #
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Email
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Email
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Email

Body Art Establishment Requirements

Plans:

  • Must show hand wash station in the cleaning room. Sink must have a wrist, foot or sensor control
  • Must show one hand wash station for every two work stations. Hand sink must be readily accessible to both work stations. Sink must have a wrist, foot, or sensor control
  • Must show an emergency eyewash station in needle building area
  • Must show an exhaust hood over needle building area. (only if applicable)
  • All other sinks in cleaning area must be labeled
  • Must show the measurements of each work station. (Must be at least 80 square feet)
  • Must show size of partitions. (Must be at least 6 feet high)

Other Requirements: (provide to Health Department)

  • A document stating: whether the ownership of the business is individual, a partnership or a corporation; hours of operation; all services provided (in detail)
  • Names and address of all practitioners and their exact duties
  • A list of all inventory of all equipment and how it is used
  • Name and address of all manufactures of all equipment, instruments, jewelry, and ink
  • Make, model and serial number of autoclave printed on the back of a photograph of the autoclave. Must also include a copy of the manufacturer’s specifications for operation
  • Proof of professional malpractice liability insurance for each practitioner
  • A copy of the informed consent forms for all procedures
  • Copy of the application for procedures, which must include the following: name of client, date of birth, proof of age, address, emergency contacts, client signature and practitioner performing the procedure
  • Copies of all aftercare requirements for all procedures
  • A copy of client medical history form
  • A copy of negative biological indicator test results
  • A written agreement with a licensed physician for consultative services, which must be resubmitted on an annual basis

Requirements for all practitioners: (provide to Health Department)

  • All operators must furnish proof of having experience in both/either body piercing or tattooing for at least 12 months. This must include a signed testament from a previous employer stating that the operator has been piercing or tattooing for at least one full year and a copy of the business license for this establishment
  • All operators must submit 10 original photographs of various tattoos and/or body piercing
    they have performed
  • All operators must submit 3 signed testaments from previous clients
  • All operators must submit evidence of completion of a blood borne pathogens course

Please remember it is your responsibility to comply with N.J.A.C. 8:27-1 “Body Art Procedures.” Under no circumstances will a Body Art establishment receive health department approval to open until all of the aforementioned requirements are met.

Permanent Cosmetics Requirements

Administration requirements-

  • A complete description of all services to be provided, names of all practitioners and their exact duties
  • Copy of informed consent for each procedure
  • Names and addresses of all manufacturers of processing equipment, instruments, and ink used for all procedures.
  • Make, model and serial number of steam autoclave to be printed on the back of a photograph of the autoclave
  • A copy of the manufacturer’s specifications for operation of autoclave
  • Proof of professional malpractice liability insurance for each practitioner
  • A current copy of a negative biological indicator test results (for autoclave)
  • Copy of application for procedures (must include: name of client, date of birth, proof of age, address, emergency contacts, client signature and name of practitioner performing the procedure)
  • Copies of all aftercare requirements for all procedures (must include care specific to each procedure, possible side effects, information regarding any physical or cosmetic restrictions, signs and symptoms of infection and instructions to consult a physician if infection occurs) must be signed by client. One copy goes to client and a second copy stored in client’s folder.
  • A copy of client medical history form (minimum: diabetes, allergies, skin conditions, list of medications being taken)
  • A written agreement with a licensed physician for consultative service (to be resubmitted on an annual basis)
  • Proof of Hepatitis B vaccination series for all practitioners
  • Written policy for latex allergies
  • Proof of completion of blood borne pathogens course for each practitioner
  • Proof of completion of 40-hour training program approved by the Society of Permanent Cosmetic Professionals or the International Micropigmentation Association for each practitioner
  • Proof of certification by the American Academy of Micropigmentation for each practitioner
  • One photograph of each of the following procedures done by each practitioner: Eyebrow, Lip liner, Full lip color and Eyeliner/eyelash enhancer

Room requirements-

  • Equipment cleaning room that is physically separated from work area
  • Handwashing sink in equipment cleaning room
  • Emergency eyewash station
  • Use disposable needles only (too many construction requirements for needles that need building)
  • Work area has to be at least 80 square feet
  • A hand sink in work area (wrist, foot or sensor operated controls)
  • Non-porous easily cleanable surfaces and chairs/beds
  • Standard first aid kit in work area
  • Posted telephone numbers of local emergency medical services, local fire department, police department, health department and health officer

Please remember it is your responsibility to comply with N.J.A.C. 8:28 “Board of Cosmetology and Hairstyling.” Under no circumstances will a cosmetology and Hairstyling establishment receive health department approval to open until all of the aforementioned requirements are met.

Telephone # at Mailing Address
Tattoo
Name of Corporate officers or Partners
Outline of Any Training Programs Offered at Event
Address of Corporate officers or Partners
Email at Establishment Location
Title of Applicant
Days of Operation
Details
Establishment Type
Hours of Operation
Body Piercing
Name of Owner or Corporation
Other
Fax # at Establishment Address
Email at Mailing Address
Name of Operator or Convention Manager
Alcohol on Premises
Name of Applicant
Address of Event
Telephone # at Establishment Location
Date Signed
Fax # at Mailing Location
  • Photograph, Negative Biological of Autoclave
  • Manufacturers Instructions of Autoclave
  • Location of Processing Area
  • Location of Sink
  • Manufacturers Instructions Ultrasonic Equipment
  • Copy of After Care Instructions for Each Procedure
  • Policies for Reporting Infections and Injuries
  • Type of Containers Used to Transport Soiled Equipment
  • Policies and Procedures for Sterilization
  • Policies for Control of Back to Original Practioner
  • Record Keeping
  • Method of Transport of Sterile Supplies
  • Copy of Client Application
  • Samples of Packaging Material and Chemical Integrators
  • Purpose for Which the Permit is Requested
  • Floor Plan Drawn to Scale
  • Description of All Services Provided
  • Name and Addresses of All Practitioners
  • Policies for Hand Washing
  • Medical Waste Gernerator ID Number
  • Policies for Collection of Regulated Medical Waste
  • Policy Regarding Minors and System to Monitor
  • Copy of Malpractice Insurance for Each Practitioner
  • Copy of Informed Consent for Each Procedure
  • Samples of Waterless Hand Washing Agent
  • Written Instructions Provided to Each Artist Before Event
    • Required Attachments
    Submit the following information by uploading files to the Documents section in the next tab
    Food Supplier Information
    Person In Charge of Licensing
    Cafeteria Contact
    Cafeteria
    Age
    Name
    Camp Director
    Age
    Previous camp administration experience
    Date Close
    Aquatics Director
    Name
    Name
    Address
    Type of Training
    State
    American First Aid Certificate
    Age
    Date Open
    MA License Number
    Name
    Expiration Date
    ZIP
    City
    Coursework in camping administration
    Type of Training
    Expiration Date
    Lifeguard Certificate issued by
    Health Care Supervisor
    Health Care Consultant
    American Red Cross CPR Certificate
    Expiration Date
    Camp Details
    Hours of Operation
    Do you provide meals?
    Type
    Previous aquatics supervisory experience
    Has a Swimming Pool?
    Description (Type of animal - # of animals)
    # of Cattle (Total)
    If any foods are cooked or prepared in advance at a location other than your base of operation, list them and state where you obtained them.
    Company
    Items cooked and/or prepared on site
    Farmers Markets
    Are you providing portable sanitary facilities for public use on site?
    Cold Foods (41 ℉ and below)
    Removal Company (if applicable)
    Base Operation/Commercial Kitchen Information
    Comany Name
    (Commercially prepared and packaged sanitizers preferred. If using a solution that you have diluted from concentrate or transferred from a bulk container, you must label and identify the contents of the container you are using. You must have appropriate test strips available to verify proper concentration being used.)

    YOU MUST HAVE A THIN-PROBE FOOD THERMOMETER AVAILABLE ON SITE


    MINIMUM COOKING TEMPERATURE OF POTENTIALLY HAZARDOUS FOOD IS 145°F (OR ABOVE)
    MINIMUM REHEATING TEMPERATURE OF POTENTIALLY HAZARDOUS FOODS IS 165 °F
    GROUND BEEF MUST BE COOKED TO A MINIMUM TEMPERATURE OF 155°F.

    HOME PREPARED FOODS ARE PROHIBITED FOR USE.

    YOUR APPLICATION MAY BE REJECTED IF YOUR SERVE SAFE, FOOD HANDLER’S CERTIFICATE OR

    COMMERCIAL KITCHEN INFORMATION IS NOT LISTED OR SUBMITTED.

    How will employees wash their hands at the booth where food is made or served?
    Bare hand contact with ready-to-eat foods is prohibited. Indicate how you will assemble/prepare/serve ready-to-eat foods
    City, State, ZIP
    Type of sanitizer that will be used on site
    Event Name
    Frequency of removal
    Foods cooked and cooled in advance
    List all foods and beverages to be served and where you obtained them from. If not applicable please type "N/A"
    Address
    Hot foods (135℉ and above)
    Company Phone #
    Event Dates and Hours
    Who will monitor supplies (toilet paper, soap, etc.) in the portable sanitary facility and on what schedule?
    Number of Units
    Do the unit(s) contain handwashing utilities?
    Specify the type(s) of container(s) you will use to transport the following foods to the event and how much time each will spend in transit.
    List all the products you are selling.
    Ready-to-eat food, no prep (raw vegetables, honey, etc.)
    Source of Potable Water (private well water is not prohibited)
    Frozen Foods
    How will utensils be washed or sanitized?
    Description (Type of animal - # of animals)
    # of Fowl/Poultry (Total)
    List Name, Address & Telephone of all Suppliers
    Mobile Vendor
    Name of Place where Truck gets cleaned
    This public recreational bathing facility will be run in accordance with the provisions of Chapter IX of the New Jersey State Sanitary Code: "Public Recreational Bathing," and with Ordinance Number 22 of the Ramsey Board of Health.
    A copy of the Certified Pool Operator's license and certifications must be attached to this application.
    Phone #
    Estimated Daily Attendance
    Duration of Season
    Name
    Certified Pool Operator Details
    ** POOL PROPERTY MUST BE FULLY READY TO OPERATE AT THE TIME OF THE PRE-OPERATIONAL INSPECTION **
    Type of Facility
    Maximum Occupancy
    Restaurants
    Do you sell Alcohol or allow BYO?
    Do you sell tobacco products?
    Hours of Operation
    # Seats (tables, bar seats, booths)
    Risk Type
    # Pedicure Chairs
    #f Manicure Chairs
    Salons
    List of Services
    # Salon Chairs
    Removal Company (if applicable)
    End
    Items cooked and/or prepared on site
    Who will monitor supplies (toilet paper, soap, etc.) in the portable sanitary facility and on what schedule?
    Hot Foods (135 ℉ and above)
    Foods cooked and cooled in advance
    Location
    Ready-to-eat food, no prep (raw vegetables, honey, etc.)
    Event Details
    How will employees wash their hands at the booth where food is made or served?
    Start
    If any foods are cooked or prepared in advance at a location other than your base of operation, list them and state where you obtained them.
    Bare hand contact with ready-to-eat foods is prohibited. Indicate how you will assemble/prepare/serve ready-to-eat foods
    Do the unit(s) contain handwashing utilities?
    Frozen Foods
    Specify the type(s) of container(s) you will use to transport the following foods to the event and how much time each will spend in transit.
    List all foods and beverages to be served and where you obtained them from. If not applicable please type "N/A"
    Are you providing portable sanitary facilities for public use on site?

    YOU MUST HAVE A THIN-PROBE FOOD THERMOMETER AVAILABLE ON SITE


    MINIMUM COOKING TEMPERATURE OF POTENTIALLY HAZARDOUS FOOD IS 145°F (OR ABOVE)
    MINIMUM REHEATING TEMPERATURE OF POTENTIALLY HAZARDOUS FOODS IS 165 °F
    GROUND BEEF MUST BE COOKED TO A MINIMUM TEMPERATURE OF 155°F.

    HOME PREPARED FOODS ARE PROHIBITED FOR USE.

    YOUR APPLICATION MAY BE REJECTED IF YOUR SERVE SAFE, FOOD HANDLER’S CERTIFICATE OR

    COMMERCIAL KITCHEN INFORMATION IS NOT LISTED OR SUBMITTED.

    Source of Potable Water (private well water is not prohibited)
    Type of sanitizer that will be used on site
    Details
    Company Name
    Contact
    (Commercially prepared and packaged sanitizers preferred. If using a solution that you have diluted from concentrate or transferred from a bulk container, you must label and identify the contents of the container you are using. You must have appropriate test strips available to verify proper concentration being used.)
    How will utensils be washed or sanitized?
    Frequency of removal
    Phone #
    Cold Foods (41 ℉ and below)
    Number of Units
    Event Name
    Add details for every Vending Machine registered under the business.
    Vending
    # of Vending machines that dispense perishable food or beverages
    # of Vending machines that dispense non-perishable food or beverages
    Establishments that Prepare or Serve Food - Provide details of at least one (1) person per shift that has a food safety certification and attach a copy of their certificate.

    Salons/Body Art/Tattoo Facilities - Provide details of all practitioners and attach copies of their cosmetology license with photo.

    Public Recreational Bathing Facilities - Provide a copy of the Certified Pool Operator's license and certifications

    New Establishments - If this is a new establishment or if renovation is planned, please attach a floor plan with the proposed layout of equipment for approval by the {[DEP]}. No business may be conducted until approval is given by the {[DEP]}.

    Fowl/Poultry/Cattle/Horses - Please submit a drawing or survey showing where the animals are kept on the property and the distance from all dwellings within 100 FT.

    Attachments
    Type Full Name :
    Sign With Hand
    Late Fee
    I certify that the information stated on this application is true and complete to the best of my knowledge and I understand that any willful, false statements are cause for rejections of this application.

    It is further understood that this license is granted only to the ownership listed on this application for the period stated.

    Place, Business and Ownership is NOT TRANSFERABLE in any form. Failure to operate the business in compliance with Chapter 24 of the New Jersey State Sanitary Code and any and all other applicable laws and regulations of the State of New Jersey and the {[CNAME]} may result in revocation of the License, and/or additional fees.

    I understand that any change in the information in this application, any alternations or additions, new construction, new animals, relocation of animals, new ownership, or equipment, must be approved by the {[DEP]} and other municipal offices prior to such action. The {[DEP]} must be notified of fires, flooding or other incidents causing interruption of operation.

    Milk/Dairy License
    License
    Certification of Applicant
    Applicant Signature *
    Amount Due