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Dmxvn of Enwormenul Health
Inspection of
Tattoo Establishment
'inspection Aare 0 6' 3 0/.2 0 1
"status Code A
Health Department
Current Facility ID
Old Facility ID
2018610209
Water Supply: Q M unicipatlCommunily ❑ On -Site Supply water sample taken today? Qinspection lame Change
�f es O No [jRe-inspection Deriiication of Closure
Wastewater. QMunicipauCommunity �OnSite System visit Status Change
'Establishment Name POLSON'S TATTOO STUDIO - JERRY Hameot JERRY TLAIL III
Tattoo A rust
Location Address: 262 1STAVE NW MailingAddr. 2456 BROOK HALLOW RD
City: HICKORY Mae NC zip 28601 City: CROUSE State NC Zip 28033
RECORDS: (.3206;.3208) comments,
1. Records maintained for each patron include namei address, phone number, •^ SEE COMMENT SHEET ATTACHED -
date of birth, and signature.................................................................... -
2. Monthly records of bacterial endospore destruction tests maintained for
each autoclave •
TATTOO ROO11: (.3205; .3207; .3208; .3210)
3. Separate and apart from areas used far other purposes ........................ -
4. Separate work stations for each artist .................................................... -
5. Room dean and good repair------------------------------------------------------------------
6. Furniture easily cleanable, kept clean .................................................... -_
7. Instruments, dyes, carbons, stencils kept in clean dosed 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.......... ........................-...... _
I I- 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. Crean 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 fingernai I 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 gashed thoroughly before each patron ---------------------------------.---- -
21. Crean disposable latex gloves worn ... ......................... ........................... -
22. Clean govm cr lap cloth used................................................................
23- Sterile instruments handled by aseptic technique ...................................
24- Ink dispensed into disposable ink caps ---------------------.----.----.-_--.-_----.---
25. Stan 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: (.32(Y7;.3208;.3209)
30- Blood and body fluidprecautions taken ................................................
31. Protective covcrings & lap cloths removed & disposed of or laundered . -
32. Contaminated Equipment cleanedand disinfected .................................. _
33_ Contaminated instruments properly stored, cleaned, and autoclaved -
34. Needles removed and placed insharps container ...................................... .... Yes � N o Comment Sheet Attached?
.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 Rept
secured ................. ......................................... ................................... Received by:
2:0:
38- Litter and solid waste not allowed to accumulate ............................
C
Inspection by- W EHS I.D. zi
1711 - Carpenter, Scott
Purpose. General Statute 130.k-283 requires the Commission br Health Services to adopt rules go%wniag tattooing. I5 a ICAC ISA.3200 specifies the requirements br tattoo artists. ibis form is
developed to be used in making inspections of nano establishments. Preparaties Local environmental health specialists shall complete the form every time they conduct =inspection. Based on
obsmawris and crfvrmatim Frovidedby tte taboo artist, place a check manic beside each item to mdxate comoiance pith the applicable rules. Prepare an cr*mal and one coW for, 1.Ongual to be
left with tattoo artist 2. Copy for the tont health department_ Specific deficiencies arc underlined_ Ifadditiena! explanation is needed, use anedser sheet Disposition: Please refer to Records
Re tend oa and Disposition 5eheduie 8-8.6., for C otnty District Health Deputrunts which is published by the North Carolina Division of Archives & History. Ad&bona I forms maybe ordered from:
Division of Environmental Health, 16321W Senice Center, Raleigh, NC 27699.1632, (Comer 5241-00)
ESS 4014 (14%iWd -.05)
Fnvveemtmul Heaah 5enticea Sactiee(R.viam 7.'0�
2
N.C. Department of Environment and Natural Resources Name: POLSOMSTATToo STUDIO -JERRY T L4IL III
Division of Environmental Health ID; 201861D209
Street: 262 1 STAVE NW
COMMENT ADDENDUM City: HICKORY
Using all disposfble - no autoclave onsite
❑am
Time In: 1 1 - 4 0❑ Pm
Dam
Time Out:
1 2 1 5 R, Pm
Total Time: 35 minutes
VI