HomeMy WebLinkAboutJamie Cain 610097 08 24 16.SC.PDFName Change
Verification of Closure
Status Change
Inspection by: ____________________________________________
N.C. Department of Environment and Natural Resources
Division of Environmental Health Health Department
Inspection of
Tattoo Establishment
Purpose: General Statute 130A-283 requires the Commission for Health Services to adopt rules governing tattooing. 15A NCAC 18A .3200 specifies the requirements for tattoo artists. This form is
developed to be used in making inspections of tattoo establishments. Preparation: Local environmental health specialists shall complete the form every time they conduct an inspection. Based on
observations and information provided by the tattoo artist, place a check mark beside each item to indicate compliance with the applicable rules. Prepare an original and one copy for: 1. Original to be
left with tattoo artist. 2. Copy for the local health department. Specific deficiencies are underlined. If additional explanation is needed, use another sheet. Disposition: Please refer to Records
Retention and Disposition Schedule 8.B.6., for County/District Health Departments which is published by the North Carolina Division of Archives & History. Additional forms may be ordered from:
Division of Environmental Health, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00)
Current Facility ID
Old Facility ID
Score:N/A
NC
Name Of
Tattoo Artist:
Mailing Addr:
State:City:Zip
Location Address:
City:
RECORDS: (.3206; .3208)
1. Records maintained for each patron include name, address, phone number,
date of birth, and signature ....................................................................
2. Monthly records of bacterial endospore destruction tests maintained for
each autoclave .......................................................................................
TATTOO ROOM: (.3205; .3207; .3208; .3210)
3. Separate and apart from areas used for other purposes........................
4. Separate work stations for each artist ....................................................
5. Room clean and good repair ..................................................................
6. Furniture easily cleanable, kept clean ....................................................
7. Instruments, dyes, carbons, stencils kept in clean closed containers, case
or storage cabinet ..................................................................................
8. Sterile instruments packaged in sterile containers ..................................
9. Rigid solid waste container with plastic liner .........................................
10. No animals or use of tobacco in tattoo room..........................................
11. No eating or drinking by artists in tattoo room ......................................
LAVATORY: (.3203; .3204; .3207; .3208)
12. Accessible to tattoo room .....................................................................
13. Use restricted to tattoo artists ...............................................................
14. Clean and good repair, kept free of storage ............................................
15. Hot and cold water under pressure, mixing faucet ..................................
16. Antiseptic soap and germicidal solution provided ..................................
17. Individual scrub brushes and fingernail files or orange sticks provided for each
artist .....................................................................................................
18. Individual disposable hand towels provided ..........................................
19. Approved water supply and sewage disposal .......................................
TATTOOING PROCEDURES: (.3208; .3209)
20. Hands washed thoroughly before each patron .......................................
21. Clean disposable latex gloves worn........................................................
22. Clean gown or lap cloth used ................................................................
23. Sterile instruments handled by aseptic technique ...................................
24. Ink dispensed into disposable ink caps .................................................
25. Skin examined and only healthy skin tattooed .......................................
26. New disposable or sterile razor used .....................................................
27. Germicidal solution applied to skin .......................................................
28. Only new sterile needles used ...............................................................
29. Tattoo cleaned and sterile dressing applied ............................................
PRECAUTIONS: (.3207; .3208; .3209)
30. Blood and body fluid precautions taken ................................................
31. Protective coverings & lap cloths removed & disposed of or laundered .
32. Contaminated Equipment cleaned and disinfected ..................................
33. Contaminated instruments properly stored, cleaned, and autoclaved .....
34. Needles removed and placed in sharps container ......................................
MISCELLANEOUS: (.3205; .3207; .3210)
35. Poisons in covered, labeled containers ..................................................
36. Premises free of vermin, flies, or mosquito breeding places ..................
37. Outdoor solid waste in watertight containers with tight lids, properly
secured .................................................................................................
38. Litter and solid waste not allowed to accumulate ............................
EHS I.D. #
Rept
Received by: ___________________________
Water sample taken today?
State:ZipNC
Comment Sheet Attached?
Comments:
** SEE COMMENT SHEET ATTACHED **
Yes No
Yes No 2
V
EHS 4014 (Revised 7/05)Environmental Health Services Section (Review 7/08)
1
//
*Establishment Name
*status Code
*Inspection Date
Inspection
Re-inspection
VisitWastewater:Municipal/Community On-Site System
Municipal/Community On-Site SupplyWater Supply:
18
201861009708242016
A
JAMIE CAINARTISTIC PURSUIT STUDIO - JAMIE
874 14TH ST DR SW
HICKORY 28602 CATAWBA
5973 HUDSON CHAPEL R
28609
1711 - Carpenter, Scott
Total Time:
N.C. Department of Environment and Natural Resources
Division of Environmental Health
COMMENT ADDENDUM
Time In:
Time Out:
City:
Street:
ID:
Name:am
pm
am
pm
:
:
ARTISTIC PURSUIT STUDIO - JAMIE CAIN
2018610097
874 14TH ST DR SW
HICKORY
1 1 0 4
1 1 0 9
5 minutes
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM City:
Street:
ID:
Name:ARTISTIC PURSUIT STUDIO -
2018610097
874 14TH ST DR SW
HICKORY
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM City:
Street:
ID:
Name:
General Comments:
ARTISTIC PURSUIT STUDIO -
2018610097
874 14TH ST DR SW
HICKORY