Tattoo Application and County Contact Info

1 DH 4147, 8/12 , STATE OF FLORIDA DEPARTMENT OF HEALTH Authority , Florida Statutes Application for Tattoo Artist License Instructions: Do not leave any item blank. Enter NA for non-applicable items. For initial license and license renewal, submit the completed Application to the County health department that has jurisdiction for the tattooing program in the County where the applicant lives. To select the County , type the following link into Internet browser: This Application must be accompanied by the following: Fee of $ (submit every year). Reactivation fee of $ for renewal of license after date of expiration.

2 A copy of a government-issued photo identification confirming at least 18 years of age (submit for initial registration only, not renewal). A copy of the certificate of training proving completion of a department approved course on blood-borne pathogens and communicable diseases with having achieved a minimum score of at least 70% on the course examination (submit for initial Application only, not renewal). DH use only: Check No. Check Amount Date Received Receipt No. Facility Permit No. Date Issued Amended Application Only Date Received Type of License: ____ Initial ____ Renewal Name of Applicant: _____ Physical Address of Applicant: _____ Street City State Zip Code Mailing Address if Different: _____ Box or Street City State Zip Code Phone Number: _(____)_____ E-mail Address: _____@_____ Provide the following information for each Tattoo establishment or temporary Tattoo establishment where the applicant will perform tattooing or intends to perform tattooing: 1.

3 _____ Name of Licensed Establishment Department of Health License Number 2. _____ Name of Licensed Establishment Department of Health License Number 3. _____ Name of Licensed Establishment Department of Health License Number The undersigned Applicant hereby agrees to practice tattooing in compliance with ss. , , and Chapter 64E-28, , and exclusively at an establishment licensed under ss. , , and Chapter 64E-28, The information contained in this Application , which serves as a basis for licensure, is true and correct. I understand that any misrepresentation of the facts in this Application , or failure to comply with sanitary standards, is grounds for denial, administrative fine and/ or revocation of the Tattoo license.

4 Further, I understand that obtaining or attempting to obtain a license or registration by means of fraud, misrepresentation, or concealment is committing a misdemeanor of the second degree punishable as provided in s. or s. _____ _____ Name of Applicant (print or type) Date _____ Signature of Applicant Alachua Department of Health in Alachua, Environmental Health Section 224 SE 24th Street, Gainesville, FL 32601 (352) 334-7930 Baker See duval Bay Department of Health in Bay County , Environmental Health Section 597 West 11th Street, Panama City, FL 32401 (850) 872-4660 Bradford See Alachua Brevard Department of Health in Brevard County , Environmental Health Section Government Center 2725 Judge Fran Jamison Way, Building A 116, Viera, FL 32940 (321) 633-2100 Broward Department of Health in Broward County , Environmental Health Section 2421 SW 6th Avenue, Fort Lauderdale, FL 33315 (954)

5 467-4700 Calhoun Department of Health in Calhoun County , Environmental Health Section 19611 State Road 20 West, Blountstown, FL 32424 (850) 674-5645 Charlotte Department of Health in Charlotte County , Environmental Health Section 18500 Murdock Circle, Suite 203, Port Charlotte, FL 33948 (941) 743-1266 Citrus See Marion Clay Department of Health in Clay County , Environmental Health Section Box 578, Green Cove Springs, FL 32043 (904) 278-3782 Collier Department of Health in Collier County , Environmental Health Section 3339 E. Tamiami Trail, Suite 145, Naples, FL 34112 (239) 252-8200 Columbia See Alachua Dade (Miami-Dade) Department of Health in Miami-Dade County , Environmental Health Section 1725 NW 167th Street, Miami Gardens, FL 33056 (305) 623-3500 DeSoto Department of Health in DeSoto County , Environmental Health Section 34 S.

6 Baldwin Avenue, Arcadia, FL 34266 (863) 993-4601 Dixie See Alachua duval duval provides service for: Baker & St. Johns County Department of Health in duval County , Environmental Health Section 900 University Boulevard N., Suite 300, Jacksonville, FL 32211 (904) 253-1785 Escambia Escambia provides service for: Okaloosa, Santa Rosa, and Walton County Department of Health in Escambia County , Environmental Health Section 1300 West Gregory, Pensacola, FL 32501 (850) 595-6700, ext. 2052 Flagler Department of Health in Flagler County , Environmental Health Section Box 847, Bunnell, FL 32110 (386) 437-7358 Franklin Department of Health in Franklin County , Environmental Health Section 137 12th Street, Apalachicola, FL 32329 (850) 653-2113 Gadsden Department of Health in Gadsden County , Environmental Health Section Physical Address: 278 LaSalle Lefall Drive, Quincy, FL 32353 Mailing Address: Box 1000, Quincy, FL 32353 (850) 875-7200 Gilchrist See Alachua Glades Department of Health in Glades County , Environmental Health Section 1021 Health Park Drive, Moore Haven, FL 33471 (863) 946-0707, ext.

7 203 Gulf Department of Health in Gulf County , Environmental Health Section 2475 Garrison Avenue, Port St. Joe, FL 32456 (850) 227-1276, ext. 125 Hamilton See Alachua Hardee See Polk Hendry Department of Health in Hendry County , Environmental Health Section 1140 Pratt Boulevard, LaBelle, FL 33975 (863) 674-4047 Hernando Department of Health in Hernando County , Environmental Health Section 7551 Forests Oaks Boulevard, Spring Hill, FL 34606 (352) 540-6800 Highlands Department of Health in Highlands County , Environmental Health Section Mailing Address: 7205 South George Boulevard, Sebring, FL 33875 Physical Address: 501 South Commerce Avenue, Sebring, FL 33870 (863) 402-6550 Hillsborough Department of Health in Hillsborough County , Environmental Health Section Box 5135, Tampa, FL 33675-5135 (813) 307-8015 Holmes Department of Health in Holmes County , Environmental Health Section 603 Scenic Circle, Bonifay, FL 32425 (850) 547-8500 Indian River Department of Health in Indian River County , Environmental Health Section 1900 27th Street, Vero Beach, FL 32960-3383 (772) 794-7440 Jackson Department of Health in Jackson County , Environmental Health Section 4487 Lafayette Street.

8 Box 310, Marianna, FL 32448 (850) 482-9227 Jefferson Department of Health in Jefferson County , Environmental Health Section 1255 West Washington, Monticello, FL 32344 (850) 342-0170 Lafayette See Alachua Lake Department of Health in Lake County , Environmental Health Section Physical Address: 315 W. Main Street, Tavares, FL 32778 Mailing Address: Box 1305, Tavares, FL 32778 (352) 253-6130 Lee Lee provides service for Lee and Charlotte County Department of Health in Lee County , Environmental Health Section 2295 Victoria Avenue, Fort Myers, FL 33901 Leon Department of Health in Leon County , Environmental Health Section 435 N. Macomb Street, Tallahassee, FL 32301 (850) 606-8350 Levy See Alachua Liberty Department of Health in Liberty County , Environmental Health Section 12832 NW Central Avenue, Bristol, FL 32321 (850) 643-2415 Madison Department of Health in Madison County , Environmental Health Section 218 SW 3rd Avenue, Madison, FL 32340 (850) 973-5000 Manatee Department of Health in Manatee County , Environmental Health Section 410 Sixth Avenue, E.

9 , Bradenton, FL 34208 (941) 748-0747 Marion Department of Health in Marion County , Environmental Health Section 1801 SE 32nd Avenue, Ocala, FL 34478 (352) 622-7744 Martin Department of Health in Martin County , Environmental Health Section 3441 SE Willoughby Boulevard, Stuart, FL 34994 (772) 221-4090 Monroe Department of Health in Monroe County , Environmental Health Section 102050 Overseas Highway, Suite 202, Key Largo, FL 33037 (305) 289-2721 Nassau Department of Health in Nassau County , Environmental Health Section Box 15100, Fernandina Beach, FL 32035 (904) 530-6800 Okaloosa See Escambia Okeechobee Department of Health in Okeechobee County , Environmental Health Section 1728 NW 9th Avenue, Okeechobee, FL 34972 Orange Department of Health in Orange County , Environmental Health Section 1001 Executive Center Drive, Suite 200, Orlando, FL 32803 (407) 858-1497 Osceola Department of Health in Osceola County , Environmental Health Section 1 Courthouse Square, Suite 1200, Kissimmee, FL 34741 (407) 742-8600 Palm Beach Department of Health in Palm Beach County , Environmental Health Section Physical Address: 800 Clematis Street, West Palm Beach, FL 33401 Mailing Address.

10 Box 29, West Palm Beach, FL 33401 (561) 837-5900 Pasco Department of Health in Pasco County , Environmental Health Section 5640 Main Street, New Port Richey, FL 34652 (727) 841- 4425 Pinellas Department of Health in Pinellas County , Environmental Health Section 8751 Ulmerton Road, Suite 2000, Largo, FL 33771 (727) 507-4336 Polk Polk County provides services for: Hardee County Department of Health in Polk County , Environmental Health Section 2090 E. Clower Street, Bartow, FL 33830 (863) 519-8330, ext. 6 Putnam See Alachua Santa Rosa See Escambia Sarasota Department of Health in Sarasota County , Environmental Health Section 1001 Sarasota Center Boulevard, Sarasota, FL 34240 (941) 861-6133 St. Johns See duval St. Lucie Department of Health in St. Lucie County , Environmental Health Section 5150 NW Milner Drive, Port St.