Tattoo/Body Piercing Artist - Mississippi State Department of Health

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STEPS TO REGISTRATIONFOR TATTOO AND/OR BODY PIERCINGEnclosed is a registration packet for Tattoo and/or Body Piercing Artist. Two types ofregistrations are currently issued in the state of Mississippi: Regular and Provisional.The requirements for each are as follows:Regular1. Completed, notarized application.2. Copy of driver’s license or social security card.3. Passport style photo (copies of photos are not acceptable)4. Application fee - $150.00 (non-refundable) per registration [$150.00 for each tattooregistration; $150.00 for each body piercing registration].5. Proof of having completed the American Red Cross “Preventing Disease Transmission”course or its equivalent.6. Verification of all current or non-current [within the last 18-months]licensure/registration, reported directly from the licensing authority (with seal).7. Copy of all current or non-current licensure/registrations.Provisional1. Completed, notarized application with required attachments.2. Copy of driver’s license or social security card.3. Passport style photo (copies of photos are not acceptable)4. Application fee - $150.00 (non-refundable) per registration [$150.00 for each tattooregistration; $150.00 for each body piercing registration].5. Proof of having completed the American Red Cross “Preventing Disease Transmission”course or equivalent.6. Completed and signed supervisory agreement form.PLEASE NOTE:iiAn inspection is required for all new locations.All requirements must be on file and satisfactory to this office before an inspection willbe ordered.
qqTattoo ArtistBody PiercingMISSISSIPPI STATE DEPARTMENT OF HEALTHOffice Use OnlyCheck No. ________Application for RegistrationAmount $ ________Date ____/____/____Personal1. Name: _________________________________________________________________________________________Last First Middle/Maiden2. Home Address: ____________________________________________ 3. Telephone Number (___) ______________4. _______________________________________________________________________________________________City State Zip Code5. Email Address: ___________________________________________________________________________________6. Social Security Number: _______-_____-_______ 7. Date of birth: ______/______/______8. Race: _____________ 9. Sex: Male q Female q 10. US Citizen: No q Yes q11. Are there any criminal or civil suits pending against you? No q Yes q12. Have you ever been convicted of any felony or misdemeanor? No q Yes q13. Have you ever had a tattoo and/or body piercing license or registration revoked or suspended? No q Yes q14. Are you now, or have you ever been licensed or registered to perform tattooing and/or bodypiercing in any state or jurisdiction? No q Yes q_____________________________ _____________________________ _____________________________Employment15. Place of Employment: _____________________________________________________________________________16. Owner: ___________________________________________________ 17. Work Telephone (___) ______________18. Employment Address: _______________________________________________________________________________________________________________________________________________________________________________City State Zip CodeMississippi State Department of Health Revised 12-05-13 Form 258 EPage 1 of 6
Page 1: Dear Applicant:Enclosed you will fi
Page 6 and 7: qqTattoo ArtistBody PiercingOffice
Page 8 and 9: Supervision Agreement for Provision
Page 10 and 11: Inspected by:NameTitleFollow-up req
Page 12 and 13: Regulations Governing Registrationo
Page 14 and 15: Rule 11.5.4 Piercing Equipment ....
Page 17 and 18: Subchapter 3: Requirements for Cert
Page 19 and 20: the Department, in its discretion,
Page 21 and 22: patron. Any dye in which the needle
Page 23 and 24: on an individual client. Under no c
Page 25 and 26: Hands shall be washed prior to donn
Page 27 and 28: e. Name of client;f. Home address o
Page 29 and 30: Rule 11.5.15 Summary Suspension: Th
Page 31 and 32: 3. That the Registrant shall have t
Page 33: Rule 11.7.4 Administrative Grievanc

Tattoo/Body Piercing Artist - Mississippi State Department of Health

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