Free F-47454 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7454 (09/99)

STATE OF WISCONSIN Bureau of Environmental Health HFS 173, Wis. Admin. Code

TATTOO & BODY PIERCING INSPECTION REPORT
NAME OF ESTABLISHMENT STREET ADDRESS CITY, VILLAGE OR TOWNSHIP COUNTY LEGAL NAME OF ESTABLISHMENT OWNER STREET ADDRESS CITY, VILLAGE OR TOWNSHIP

LEGAL NAME OF LICENSED PRACTIONER(S)

PRACTIONER LICENSE NUMBER(S) (PREFIX INDICATES TYPE)

TYPE OF OPERATION TATTOO BODY PIERCING ESTABLISHMENT LICENSE NUMBER

BOTH

NAME OF PREVIOUS LICENSED ESTABLISHMENT

NAME OF PREVIOUS LICENSED OWNER

SURVEY DATE ESTABLISHMENT PHONE NO.

INSPECTION STATUS

LICENSE STATUS

RELEASE DATE

Release ....................................1 Pre-Inspection.......................... 1 INSPECTION TIME Conditional ...............................2 Pre-Inspection Follow-Up ......... 2 st Withhold ...................................3 1 Inspection............................ 3 TEMPORARY PERMIT Suspend ...................................4 Reg. Inspection ........................ 4 Valid from ________________ through HOURS OF OPERATION Operational...............................5 Follow-Up................................. 5 __________________ Other ........................................6 Complaint................................. 6 Other........................................ 7 OPERATOR -- The violations in operating procedure or physical arrangement indicated below must be corrected by the next routine inspection or such period of time as may be specified.

FACILITY, PRACTIONER & PATRON REQUIREMENTS 1 _____ *Age restriction, signed informed consent form provided for each patron. 2 _____ Establishment separate from living quarters. 3 _____ *Handwashing facilities located convenient to the application area, hot or tempered water provided, single-service towels & anti-bacterial hand soap provided. 4 _____ Proper construction of application area: walls & ceiling smooth, light-colored, easily cleanable; floors, smooth, nonporous, clean & in good repair, carpeting prohibited. 5 _____ Premises & all facilities used in connection with the premises maintained in clean, sanitary & vermin-free condition. 6 _____ Smoking & consumption of food not permitted in procedure area; animals except approved for disabled persons prohibited in the establishment. 7 _____ Proper personal hygiene practices during procedures, clean washable outer clothing. 8 _____ Tattooists use single-use plastic covers to cover spray bottles & other reusable accessories. 9 _____ Use of razors: disposable for single-use only, electric cleaned & disinfected between patrons. 10_____ All surfaces, counters & general use equipment cleaned & disinfected before each patron is seated. 11_____ Sufficient lighting provided: minimum of 50 ft. candles provided in application areas. 12_____ Toilet with handwashing facility clean, in good repair & separate from any living area; a handwash facility provided convenient to tattoo/body piercing area, soap in a dispenser and single-service towels provided at all handwashing facilities. *Items require immediate correction or a scheduled re-inspection.

13_____ *Waste, including infectious waste, properly identified, stored & disposed in a manner consistent with NR 526. 14_____ *Proper personnel hygiene: clothing clean, single-service gloves worn during procedure & changed if interruption occurs. 15_____ Skin of patron cleaned & antiseptic applied with cotton gauze or single-use toweling. 16_____ Patron provided with proper verbal and written instructions on care of tattoo or body-piercing. 17_____ Privacy barrier sufficient to provide privacy, available upon patron request. CLEANING & STERILIZATION OF EQUIPMENT 18_____ Reusable equipment kept in covered stainless steel container and immersed in detergent or disinfectant solution until cleaned & sterilized. 19_____ Tattoo machine cleaned & disinfected before use. 20_____ *Reusable equipment or utensils pre-cleaned with warm water, soaked in protein dissolving detergent enzyme cleaner, then placed in an ultrasonic cleaner. 21_____ *Sterilization conducted according to manufacturer's instructions, heat sensitive indicators used for each batch, autoclave spore tested at least monthly by an independent laboratory. 22_____ Sterilized equipment properly labeled & stored. 23_____ *Sterilization records including spore tests properly maintained.

SIGNATURE - Licensee or Employee

SIGNATURE - Sanitarian

DISTRIBUTION :

OPERATOR - Copy 1

REGIONAL OFFICE - Copy 2

CENTRAL OFFICE - Copy 3