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Name Change Verification of Closure Status Change Inspection by: ____________________________________________ Community On-Site System Community Transient Non-Community Non-Transient
Non-Community Non-Public Water Supply 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 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: Date of Insp/Chg: Status Code: N/A NC Name Of Tattoo Artist: Mailing Addr: State: Zip City: Location Address: City: Name of Establishment: 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 Water sample taken today? Wastewater System:
12 34 1 2 State:NC Zip Comment Sheet Attached? Comments: ** SEE COMMENT SHEET ATTACHED ** Yes No Yes No Inspection Re-inspection Visit 2V DENR 4014 (Revised 7/05) Environmental Health
Services Section (Review 7/08) 1 //18 10 05 2009 2018610087 A JEFF JACKSON JEFF JACKSON STUDIO 258 CONOVER CONOVER 28613 1655
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM Time In: Time Out: Total Time: City: Street: ID: Name: : am pm am JEFF JACKSON
: pm 2018610087 STUDIO 258 CONOVER 0 9 3 5
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: JEFF JACKSON 2018610087 STUDIO 258 CONOVER
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: General Comments: JEFF JACKSON 2018610087 STUDIO 258 CONOVER