dear body art establishment applicant€¦ · 1. information on each employee of the body art...

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Dear Body Art Establishment Applicant: Prior to opening a Body Art Establishment, the Weld County Code Section 14 “Rules and Regulations for Body Art Establishments” requires that a representative of the facility submit a Complete Application including Plan Review for review and approval to the Weld County Department of Public Health and Environment (WCDPHE). The electronic version is available at: http://www.colocode.com/weld/weld_14_a5.pdf A complete application consists of:

• license application and fee • information form • a complete set of plans, including written specifications and supporting documents (see attached check list) • approval from local regulatory departments (Building, Fire, Sewer, Water, and Zoning)

Please allow adequate time (at least 30 days) to complete the review process and obtain approval from all regulatory departments. The following is a breakdown of charges that will be incurred through the licensing process: Body Art Facility License (Inc. Mobile Units) $350.00 Application Fee $100.00 Plan Review and/or Real Estate Site Review $50.00/hr Body Art Facility Delinquent License Surcharge $75.00

All fees must be paid to WCDPHE BEFORE a Body Art Establishment License will be granted and the facility can open. If the facility is found in operation, enforcement will ensue.

To assist you with this process, we have enclosed a self inspection form and a copy of the rules and regulations for body art establishments as approved by the Board of County Commissioners. Fill out all forms in detail and return all paper work at the same time to the health department. Two inspections may be required prior to opening. We suggest that you allow 7-10 working days to schedule the preliminary walk-through and final pre-opening inspections. Once you have submitted your plan and it has been reviewed, you will receive written notification that the plans are approved or that additional information is required. If additional information is required to complete the plan review process, the applicant is responsible for providing this information or complying with additional requirements. Failure to provide the required information could delay the review process substantially. Please notify the department of any changes in plans/blueprints. Revised blueprints/layout may be required to be submitted for review. This department may assess additional fees if significant changes to plans are performed after receiving initial approval. If you have any questions concerning the above requirements, please contact us at (970) 304-6415 or send your information to Environmental Health Services at the address at the top of this letter.

http://www.colocode.com/weld/weld_14_a5.pdf

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Body Art Plan Review Check List For Application:

1. Information on each employee of the body art establishment. This includes: a. Full Legal Name b. Home Address c. Phone Number d. Proof that all employees handling sharps and/or infectious waste have either completed or were

offered and declined, in writing, the Hepatitis B vaccination series. This offering shall be included as a pre-employment requirement and comply with Section 14-5-30.B.

2. Written procedures specific to tattooing. 3. Written procedures specific to piercing 4. Written universal precautions procedure/training (may include certification) 5. Hepatitis B (HBV) Vaccination statement or Declination Statement 6. Client Consent Form 7. Aftercare Instructions 8. Written Plan for Infectious Waste Management 9. Bio-hazardous Waste Contract Service Agreement from Disposal Company 10. Written Plan for Instrument Cleaning and Sterilization 11. Contract Service Agreement for Spore Testing 12. Written Plan for Cleaning and Disinfection of Procedure List 13. Antiseptic and Disinfectant List-Including MSDS Sheets 14. Detailed Floor Plan Including Customer Waiting Area, Procedure Rooms, Hand sinks, Bathrooms, Utility Sink,

Water Heater 15. Construction Schedule

Other Local Regulatory Approval forms that are also required for Body Art Facilities:

16. Fire Department Approval Form 17. Building Department Approval Form 18. Zoning Department Approval Form 19. Sewage Department Approval Form 20. Water Department Approval Form

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Guidelines for the Use of Disinfectants in Body Art Facilities Weld County Public Health and Environment

All disinfecting agents used in Body Art facilities shall be registered with the U.S. Environmental Protection Agency (EPA). The EPA classifies disinfectant products based on the number and stringency of tests they are required to pass. Disinfectants must be shown to be effective against 99.99% of bacteria in multiple tests. Disinfectants are further classified into three categories, depending on effectiveness: limited efficacy, general efficacy and hospital disinfectants. Products registered as hospital disinfectants will usually have label information indicating effectiveness against Salmonella enterica (also known as Salmonella choleraesuis), Staphylococcus aureus and Pseudomonas aeruginosa. The EPA requires that hospital disinfectants are proven effective against these three organisms. Disinfectants should be used on hard surfaces to destroy infectious bacteria and fungi. In Body Art facilities, hospital disinfectants shall be used on surfaces known to be or commonly contaminated with bodily secretions and excretions. There are a number of chemical agents approved for disinfecting in Body Art facilities. To evaluate the use of a particular product, follow these guidelines: For diapering areas or other surfaces contaminated with bodily secretions or excretions (blood, vomit, feces, urine, sputum and mucus), the product is approved if:

• It is registered with the EPA as a hospital disinfectant effectiveness against Salmonella enterica (also known as Salmonella choleraesuis), Staphylococcus aureus and Pseudomonas aeruginosa;

• It is used according to the manufacturer’s instructions, including concentration, contact time, method, and surfaces.

• Checking the contact time is very important as products vary from 1-15 minutes of contact time. This means that the chemical agent must remain wet on the surface for the contact time specified on the product’s label.

Chlorine Disinfectant

The most commonly used and approved chemical disinfecting agent is sodium hypochlorite (chlorine bleach). Bleach can be used to sanitize or disinfect, depending on the dilution or concentration prepared. Common household bleach (i.e., Clorox) usually contains 8.25% sodium hypochlorite. If the label on the household bleach specifies a percentage of sodium hypochlorite other than 8.25%, the following recipe will not be accurate and the solution must be made according to labeled instructions. Chlorine test strips should also be used to verify the concentration of the disinfectant solution.

Application: • 1/2 cup or 8 tablespoons or 4 ounces of chlorine bleach (8.25% sodium hypochlorite) per gallon of water or, • 1/8 cup or 2 tablespoons or 1 ounces of chlorine bleach (8.25% sodium hypochlorite) per quart of water • Concentration for disinfectant is 2,500 ppm + of chlorine bleach • Contact time is at least five minutes • And a final rinse step

EPA Hospital Disinfectants Below is a link to current hospital disinfectants and EPA registration numbers (located on the label). Use this link as a guide to find other approved disinfectants. http://www.epa.gov/oppad001/chemregindex.htm ADDITIONAL INFORMATION AND GUIDANCE All disinfectants must be used in a manner consistent with their labeling. If, after reading a label, you question its use, please do not hesitate to contact your local health department. Guidance is also available from the National Pesticide Information Center at 1-800-858-7378

http://www.epa.gov/oppad001/chemregindex.htm

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This application will be rejected unless all questions are fully answered, proper remittance is attached, and Health Department approval is obtained. Make remittance in the correct amount and payable to: WCDPHE Type of License Applying for (check one)

Body Art Establishment (fee $ 350.00) Temporary Special Event Body Art Facility (fee $350.00) Mobile Body Art Vehicle (fee $350.00)

Establishment Name ___________________________________ Site Address ____________________________________ City _________________ State ______ Zip __________ Mailing Address _________________________________ City ________________ State _____ Zip ___________ Phone Number: (___) ______________________ Manager/Contact Person ________________________________ Hours of Operation: Days S M T W Th F S Business Hours ________to ________ (circle all that apply) Owner Name _________________________________________________________________________________ Corporation Name _____________________________________________________________________________ Owner Address ________________________________________City ________________ State ____ Zip _______ Home Phone No. (___) ____________________________ Work Phone No. (___) __________________________ Owner Mailing Address ______________________________________City ____________ State ___ Zip ________ Email __________________________________________________

SEND LICENSE/RENEWALS TO:

Owner Mailing Address Establishment Site Address, Establishment Mailing Address Or:_______________________________________________

__________________________________________________________________________________ Previous Establishment Name ________________________________________________________ (if applicable)

BODY ART ESTABLISHMENT APPLICATION FOR LICENSE

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FOR MOBILE BODY ART ESTABLISHMENTS ONLY: Vehicle Make: __________________ Model: _________ Year _____ VIN# _______________ Driver’s License No.:____________________ (For Mobile Establishments Only) FOR TEMPORARY FACILITY ONLY: Name and Location of Event: _____________________________________________________ Date/Times of Event: ___________________________ Sponsor of Event: _________________

Oath of Applicant I declare that this application and all attachments are true, correct, and complete to the best of my knowledge. _________________________________________ Date _________________ Owner/Operator Signature & Title

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Body Art Plan Review

*The following items (#1-#20) must be submitted for your application to be considered complete.

1. Written information on each employee of the body art establishment.

a. This includes: i. Full Legal Name

ii. Home Address iii. Phone Number iv. Proof that all employees handling sharps and/or infectious waste have either completed or

were offered and declined, in writing, the Hepatitis B vaccination series. This offering shall be included as a pre-employment requirement and comply with Section 14-5-30.B. (see page 2 for Hepatitis B Vaccination/Declination Form)

2. Written procedures specific to tattooing: 3. Written procedures specific to piercing:

4. Written universal precautions procedure/training (may include certification):

To demonstrate your knowledge of Universal Precautions you must attach either:

• A copy of a license or registration from a jurisdiction that requires Universal Precautions training, OR

• A Certificate of Completion for a Universal Precautions training course offered by the American Red Cross or equivalent.

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5. HEPATITIS B VACCINATION Please have each artist fill out. Prior to working in a body art establishment, all persons with the potential for handling sharps and / or infectious waste must complete the following certification regarding hepatitis B. Check either of the statements that apply: ( ) I have been vaccinated against the hepatitis B virus and a copy of my vaccination

certification is attached. ( ) I understand that due to my potential occupational exposure to blood of other

potentially infectious materials I may be at risk of acquiring hepatitis B (HBV infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the hepatitis B vaccine, I understand that I can receive the vaccination series at no charge to me.

_________________________________ _________________________________ Print Signature Sign Signature __________________________________ _________________________________ Facility Name Date

NOTE: This document must remain on file and be available for inspection while the above named employee is employed by the facility and for a minimum of one (1) year after the employee has terminated their employment.

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CLIENT CONSENT RECORDS

6. Please provide a copy of your client consent form. The body art establishment must obtain from the client or provide to the client all the following information (records must be maintained for three years):

• Personal information, procedure details

• Client’s name • Client’s address • Client’s current phone number • Date of procedure • Type of body art • Location of body art • Sterilization date of lot number of any instrument used during the procedure

o Including all needles, tubes, grips, calipers, punches, jewelry, etc. • Manufacturer and lot number of the ink used

o If a lot number is not provided for the ink, the date that the ink was received should be used

o List all colors used with the corresponding ink manufacturer and lot number

• Does client have (or has client had) any of the following? • Diabetes • Communicable disease • Hemophilia • Skin disease or lesions • Allergies or sensitivities to pigments, dyes, soaps or disinfectants • Use of anticoagulant medication • Use of any medication that would thin the blood or interfere with coagulation • It is suggested, but not required, to ask about allergy or sensitivity to Latex • It is suggested, but not required, to ask about history of epilepsy, seizures, fainting

or narcolepsy

• Provide written information regarding risks involved in the procedure, outcomes and aftercare, including:

• The body art establishment name, address, phone number and the name of the artist who performed the procedure

• Advice that the client should see a physician if any adverse reactions take place (swelling, infection, heat, illness, allergic reactions, rash, pus, etc.)

• Advise that tattoos are permanent and that they may only be removed with a surgical or laser procedure and that the removal may result in scarring

• Care instructions specific to the body art procedure performed • Explanation of the healing process • Explanation of the duration of the healing • Explanation of any possible side effects (scarring, allergic reactions, migration of

piercing, etc.) • Explanation of any abnormalities • Explanation of all restrictions or limitations during the healing (no swimming, hot

tubs, sunbathing, tanning, picking or scratching, etc.) • Indication that facility is licensed by Weld County Health Department (WCDPHE)

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7. Attach After Care Instructions for Clients

8. Written Plan For Infectious Waste Management Body art facilities will generate bio-hazardous waste during the course of their operation, including disposable sharps (instruments), blood-stained bandages, towels etc. that must be properly handled and disposed of at an approved off-site facility. Prior to commencing operation you must have made arrangements for the handling of bio-hazardous waste with an approved company.

Describe what your plan is for managing infectious waste:

9. ATTACH a copy of your service agreement with a bio-hazardous waste removal

company

10. Written Plan for Instrument Cleaning and Sterilization: a. Describe what your plan is for instrument cleaning and sterilization:

b. Will you be using only single-use, disposable instruments? □ YES □ NO

c. Please list all single-use, disposable items (needles, tubes, clamps etc.)

d. Will you be sterilizing the instruments onsite? □ YES □ NO

e. If YES, attach specification sheets for autoclave and copies of the forms you will use for STERILIZER LOGS and the required SPORE TEST LOGS.

f. If NO, list source of sterilized instruments:__________________________

All sterilized instrument packages, whether purchased pre-sterilized or sterilized within your facility, will no longer be considered sterile six (6) months after the date of sterilization.

11. ATTACH a copy of your service agreement with a spore-testing service

12. Written Plan for Cleaning and Disinfection of Procedure Area List:

13. Antiseptic and Disinfectant List-Including MSDS Sheets ONLY EPA APPROVED HOSPITAL GRADE CHEMICALS WILL BE ALLOWED TO BE USED TO DISINFECT IN THE BODY ART FACILITY.

a. Please list all chemicals used in your body art facility and the purpose of each.

Chemical Name Purpose

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14. Detailed Floor Plan of the Facility

Include Dimensions of Rooms including Customer Waiting Area, Procedure Rooms, Equipment Cleaning/Sterilizing Room (if applicable). Include location of hand sinks, restrooms, utility sink, and water heater:

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15. Construction Schedules

INTERIOR ROOM FINISH SCHEDULE

Complete the following, showing the various finish materials for each room:

Waiting area

Procedure Areas *

Storage Areas

Equipment Cleaning/Sterilizing

Room (if applicable)

Restroom

Dimensions of Room

Work Surfaces Floors Walls Ceilings Floor/ Wall Junction

*Each procedure area must be a minimum of 100 square feet.

BASIC INTERIOR FINISH REQUIREMENTS All interior surfaces shall be durable, smooth, non-absorbent and easily cleanable. Typical materials include: WORK SURFACES: Shall be durable, smooth, non-absorbent and easily cleanable.

FLOORS: Industrial grade linoleum, quarry tile, coated and sealed cement. Commercial-type carpet is permitted ONLY in office and waiting area. Carpet is not allowed in procedure areas. Storage areas and restroom areas shall be linoleum, tile or similar material. WALLS: Stainless steel panels, fiber-reinforced plastic (FRP) board, tile (sealed), painted and sealed gypsum board.

CEILINGS: Painted and sealed gypsum board; painted and sealed acoustical tile. FLOOR/WALL JUNTIONS shall be tightly covered with cove base to facilitate cleaning and maintenance.

PLUMBING SCHEDULE

Complete the table on the following page showing the number of fixtures per room. Write ‘N/A’ if that fixture will not be present in that room. Unless separate restrooms are provided, show all restroom fixtures in the ‘shared restroom’ row. The following plumbing fixtures are required for each body art facility: PROCEDURE AREAS: At a minimum, a hand sink with hot and cold running water mixing faucet, soap and paper towels for EACH procedure area. RESTROOM: At a minimum a water closet (toilet) and hand sink with hot and cold water mixing faucet, soap and paper towels.

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STERILIZATION ROOM: If single-use, single packaged instruments are not used - needles, bars, jewelry, tweezers, etc.- This room must contain a hand sink, and separate equipment washing sink for washing instruments prior to loading in autoclave for sterilizing. OTHER: All sinks shall be provided with cold water and hot water (not exceeding 120 degrees F for sinks accessible by children) as well as soap and paper towel dispensers or hand-drying device. A utility sink is required for all facilities.

ROOM Hand sinks Urinals Toilets Utility Sink (Required)

Procedure area 1 Procedure area 2

Procedure area 3

Men’s restroom Women’s restroom

Shared restroom

Sterilization room Utility Room

Totals

WATER HEATER: Please provide the following information regarding the facility water heater(s):

Gas or Electric Make Model BTU/Kilowatts 90° Recovery Rate

OTHER REQUIREMENTS

LIGHTING: At least fifty (50) foot candles of artificial light shall be provided at the level where the procedure is performed.

EQUIPMENT SURFACES: All surfaces, including but not limited to counters, tables, equipment chairs recliners, shelving and cabinets in the procedure area and instrument cleaning room shall be made of smooth, nonabsorbent materials to allow for easy cleaning and disinfection.

Other Local Regulatory Approval forms that are also required for Body Art Facilities:

16. Fire Department Approval Form 17. Building Department Approval Form 18. Zoning Department Approval Form 19. Sewage Department Approval Form 20. Water Department Approval Form

WATER DEMAND CALCULATIONS

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Weld County Department of Public Health and Environment

Occurrence Report for Body Art

Section 14-5-50 of the Weld County Code Ordinance 2002-8 requires that all serious infections, complications or diseases resulting from any body art procedure that become known to the person in charge/body artist shall be reported to the Weld County Department of Health and Environment within 24 hours after discovery. INSTRUCTIONS: Complete each item in the report. If any item does not apply to the situation, please write “N/A.” If you have any questions about completing this form, please call 970-304-6415 between the hours of 8:00 AM and 5:00 PM, and request assistance from one of the body art facility inspectors. Mail or fax the report to: Weld County Department of Public Health and Environment Attn: Consumer Protection Manager 1555 North 17th Avenue Greeley, CO 80631 Fax: 970-304-6411 Facility name: Facility address: Facility phone number: Name of studio owner: Name of person completing report: Title: Date of report: Date you were aware of infection, complication or disease: Description of occurrence (include dates, times, location of body art, description of body art, type of problem with body art, what care the facility provided to the described area, what advice the client was provided): Name of anyone who witnessed the occurrence:

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Weld County Department of Public Health and Environment Body Art Establishment Pre-Opening or Pre-Inspection Checklist

Use this checklist to help you open a new body art business or on a yearly basis to make sure you are in compliance with major

regulations □ Business and health department licenses posted in a prominent location □ Employee records available □ Universal precautions education □ Hepatitis B Certificate or Declination □ Full name, home address and home phone □ Sharps/Biohazardous materials □ Waste disposal agreement □ Containers in place □ Written infection and exposure control plans □ Spore test every 30 days (and spore test log and results) □ Client consent forms (Records must be maintained for 3 years) □ After care instructions, including when to seek medical care for complications □ Sterilizer is designed and labeled as a medical instrument sterilizer and manufacturer’s information is available □ Sterilizer load log shall be used and records maintained for 3 years □ Hand sink: □ Accessible to procedure area □ Stocked with soap and paper towels □ All sinks in facility are used only for their designated purpose □ All chemicals are properly labeled, stored and used according to label instructions □ Only fish aquariums and service animals are allowed in the waiting and non-procedural areas □ Smoking, drinking and eating are prohibited in the procedure and instrument cleaning areas

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OSHA BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN Facility: _________________________________ Address: ___________________________________ Date of Preparation: _____________________________________ Supersedes the previous plan dated: _______________________________ • The Model Exposure Control Plan is intended to serve employers as an example exposure control plan which is required by the Bloodborne Pathogens Standard. • A central component of the requirements of the standard is the development of an exposure control plan (ECP). • The intent of this model is to provide small employers with an easy-to-use format for developing a written exposure control plan. Each employer will need to adjust or adapt the model for their specific use. • The information contained in this publication is not considered a substitute for the OSH Act or any provisions of OSHA standards. It provides general guidance on a particular standard-related topic but should not be considered a definitive interpretation for compliance with OSHA requirements. • The reader should consult the OSHA standard in its entirety for specific compliance requirements. • The ECP should be updated each year. • Each employee shall read the ECP. Records indicating that the employee read the ECP should be kept in the employee file. POLICY • The (Facility Name) _____________________________________ is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens. • The ECP is a key document to assist our firm in implementing and ensuring compliance with the standard, thereby protecting our employees. • This ECP includes: _ Determination of employee exposure _ Implementation of various methods of exposure control, including: _ Universal precautions _ Engineering and work practice controls _ Personal protective equipment _ Housekeeping _ Hepatitis B vaccination

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_ Post-exposure evaluation and follow-up _ Communication of hazards to employees and training _ Recordkeeping _ Procedures for evaluating circumstances surrounding an exposure incident • The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP. PROGRAM ADMINISTRATION • __________________________________ is responsible for the implementation of the ECP. • _________________________________ will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. • Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP. • _________________________________ will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. • _________________________________ will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. • ________________________________ will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. • ____________________________will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives. EMPLOYEE EXPOSURE DETERMINATION • The following is a list of all job classifications at our studio in which all employees have occupational exposure: Tattooist Piercer Apprentice Other: ___________________________________ • The following is a list of job classifications in which some employees at our studio have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals: Receptionist Handling Dirty Jewelry Janitorial duties Handling regulated waste First aid Janitor Janitorial duties Handling regulated waste First aid Counter help Handling Dirty Jewelry Janitorial duties Handling regulated waste First aid Other Employee: _________________________________________________________ METHODS OF IMPLEMENTATION AND CONTROL Universal Precautions • All employees will utilize universal precautions.

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Exposure Control Plan • Employees covered by the blood borne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting (Name of responsible person) _______________________________________________________. • If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request. • ________________________________________________ is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. Engineering Controls and Work Practices • Engineering controls and work practice controls will be used to prevent or minimize exposure to blood borne pathogens. The specific engineering controls and work practice controls used are listed below: Circle all that apply.

• Disposable gloves are worn during procedures. • Hands are washed any time gloves are changed • Receiving tubes are used during piercing • Corks are used during piercing to receive the sharp • Piercing area has a designated space where all contaminated instruments and sharps are • placed. • Sharps containers are located below work surfaces • Sharps containers are located so contaminated sharps do not cross over work surfaces • Disposable tattoo tube and grip combinations are used • Tattoo needle and bar combinations are not broken after use • Disposable razor handles are not broken after use (Creating a sharp) • Disposable razors are placed in sharps containers after use. • Face shields are used when instruments are cleaned. • Goggles and masks are used when instruments are cleaned. • Heavy duty gloves are worn when instruments are cleaned. • Contaminated equipment is placed in transport containers when it is taken to the bio hazard • room. • Other:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Sharps disposal containers are inspected and maintained or replaced by ___________________________every ___________________ or whenever necessary to prevent overfilling.

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• This facility identifies the need for changes in engineering control and work practices through: • Review of OSHA records • Review of OSHA web site • Review of industry publications • Consultant • Training at safety conference or seminars • Review of Centers for Disease Control web site and literature • Health dept suggestions • Employee suggestions • Other: ______________________________________________________

• We evaluate new procedures or new products regularly by • Review of industry publications • Internet • Health dept suggestions • Employee suggestions • Other: ______________________________________________________ • ________________________________________________________________

• Both front line workers and management officials are involved in this process through: • Monthly meetings • Regularly scheduled meetings • Accident reviews • Other____________________________________________________________ • ___________________________________________________________________ • ___________________________________________________________________ • ___________________________________will ensure effective implementation of these recommendations.

Personal Protective Equipment (PPE) • PPE is provided to our employees at no cost to them. • Training is provided by ___________________________________________ in the use of the appropriate PPE for the tasks or procedures employees will perform. • The types of PPE available to employees are as follows:

• Disposable gloves • Full face shield • Heavy duty gloves for cleaning • Mask • Eye goggles • Mask with eye shield attached • Exposure Control Plan • Disposable aprons • Splash barrier • Other ___________________________________________________________

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• PPE is located at ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ • PPE may be obtained through (Name of responsible person) ___________________________________________________________ • Specify how employees are to obtain PPE, and who is responsible for ensuring that it is available ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ • All employees using PPE must observe the following precautions: _ Wash hands immediately or as soon as feasible after removal of gloves or other PPE. _ Remove PPE after it becomes contaminated, and before leaving the work area. _ Used PPE must be disposed of in ________________________________________ ___________________________________________ (List appropriate containers for storage, laundering, decontamination, or disposal.) _ Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; _ Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised. _ Utility gloves may be decontaminated for reuse if their integrity is not compromised; _ Discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration. _ Never wash or decontaminate disposable gloves for reuse. _ Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth. _ Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface. The procedure for decontaminating face shields is as follows: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________ The procedure for decontaminating goggles is as follows: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________

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The procedure for decontaminating utility gloves is as follows: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________ The procedure for handling used PPE is as follows: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________ Other:______________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ____________________________________________________________________ Housekeeping • Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling. • The procedure for handling sharps disposal containers is: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________ • The procedure for handling other regulated waste is: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ • Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are located in each procedure area and in the clean room, and in the following areas ______________________________________________________________. • New sharps disposal containers are obtained by ___________________________________________________________________________ ___________________________________________________________________________ • Soak trays are cleaned and decontaminated as soon as feasible after visible contamination.

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Soiled Clothing • If an employees clothing becomes contaminated with blood or other potentially infectious materials the following procedure must be followed to reduce risk of cross contaminating. ______________________________________________________________________________ ______________________________________________________________________________ • The following laundering requirements must be met: _ Handle contaminated clothing as little as possible, _ With minimal agitation place wet contaminated clothing in leak-proof, labeled or color-coded containers before transport. Use red bags or bags marked with biohazard symbol for this purpose. _ Wear the following PPE when handling and/or sorting contaminated clothing: _________________________________________________ Labels • The following labeling method(s) is used in this facility:

• Sharps Containers Color and Label Type __________________________________ • Regulated waste cans in procedure areas Label Type and Color ____________________ • Regulated waste containers in bio hazard room Label Type ________________________ • Biohazard room Label Type __________________________________________________ • Other areas or containers: • __________________________________________________________________________________________

____________________________________________________________________________________

• _______________________________ will ensure warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. • Employees are to notify ___________________________________________if they discover regulated waste containers, contaminated equipment, etc. without proper labels. HEPATITIS B VACCINATION • __________________________________ will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability. • The hepatitis B vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. • Vaccination is encouraged unless: _ Documentation exists that the employee has previously received the series, _ Antibody testing reveals that the employee is immune, or _ Medical evaluation shows that vaccination is contraindicated. • However, if an employee chooses to decline vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost. • Documentation of refusal of the vaccination is kept at ____________________. • Vaccination will be provided by

• Denver Health Medical Center at 605 Bannock Street, Denver CO. • Other:

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• Following the medical evaluation, a copy of the health care professional's Written Opinion will be obtained and provided to the employee. It will be limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was administered. POST-EXPOSURE EVALUATION AND FOLLOW-UP • Should an exposure incident occur, contact _____________________________ at the following number: _________________. • An immediately available confidential medical evaluation and follow-up will be conducted by ___________________________________________________ • Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed: _ Document the routes of exposure and how the exposure occurred. _ Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law). _ Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity; document that the source individual's test results were conveyed to the employee's health care provider. _ If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed. _ Assure that the exposed employee is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality). _ After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status _ If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; _ If the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible. ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOWUP • ________________________ ensures that health care professional(s) responsible for employee's hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's bloodborne pathogens standard. • _____________________ ensures that the health care professional evaluating an employee after an exposure incident receives the following: _ A description of the employee's job duties relevant to the exposure incident _ Route of exposure _ Circumstances of exposure _ If possible, results of the source individual's blood test _ Relevant employee medical records, including vaccination status • _______________________provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.

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PROCEDURES FOR EVALUATING THE CIRCUMSTANCES SURROUNDING AN EXPOSURE INCIDENT • _____________________________ will review the circumstances of all exposure incidents to determine: _ Engineering controls in use at the time _ Work practices followed _ A description of the device being used (including type and brand) _ Protective equipment or clothing that was used at the time of the exposure incident _ Location of the incident _ Procedure being performed when the incident occurred _ Employee’s training • _______________________________ will record all percutaneous injuries from contaminated sharps in the Sharps Injury Log. • If it is determined that revisions need to be made, ________________________________ will ensure that appropriate changes are made to this ECP. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.).

EMPLOYEE TRAINING • All employees who have occupational exposure to blood borne pathogens receive training conducted by____________________________________________ • Attach a brief description of their qualifications ___________________________________________________________________________ ___________________________________________________________________________ _____________________________________________________ • All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. • The training program covers, at a minimum, the following elements: _ A copy and explanation of the standard _ An explanation of our ECP and how to obtain a copy _ An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident _ An explanation of the use and limitations of engineering controls, work practices, and PPE _ An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE _ An explanation of the basis for PPE selection _ information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge _ Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM _ An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available _ Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident _ An explanation of the signs and labels and/or color coding required by the standard and used at this facility

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_ An opportunity for interactive questions and answers with the person conducting the training session. • Training materials for this facility are available at ______________________.

RECORDKEEPING Training Records • Training records are completed for each employee upon completion of training. • These documents will be kept for at least three years at ______________________________________________________ • The training records include: _ The dates of the training sessions _ The contents or a summary of the training sessions _ The names and qualifications of persons conducting the training _ The names and job titles of all persons attending the training sessions • Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be addressed to ____________________________________________________________.

Medical Records • Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records."

• __________________________________ is responsible for maintenance of the required medical records.

• These confidential records are kept at ________________________________ for at least the duration of employment plus 30 years. • Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to _________________________________ OSHA Recordkeeping • An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by ___________________________________.

Sharps Injury Log (available on line at www.denvergov.org/phi in the forms section) • In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log.

• All reports of incidences must include at least: _ The date of the injury _ The type and brand of the device involved _ The department or work area where the incident occurred _ An explanation of how the incident occurred. • This log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that they cover. • If a copy is requested by anyone, it must have any personal identifiers removed from the report.

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HEPATITIS B VACCINE DECLINATION (MANDATORY for each employee to complete) (available on line at www.denvergov.org/phi in the forms section) I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Signed: (Employee Name)______________________________ Printed Name: _______________________________________ Date: ________________________

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LOCAL BUILDING DEPARTMENT APPROVAL

Please complete the following information and have your local building inspection representative complete the section indicated. Once the form is completed, submit to the address stated below.

Body Art Establishment Name: __________________________________ Building Permit Number _________ Body Art Establishment Address: _______________________________________________________________ City: _____________________ State _____Zip Code: _____________ Phone Number : (_____)________________________ Tax I.D. Number: ________________________________ Square Footage: _______________________________ Occupancy Load: _______________________________

THIS SECTION FOR BUILDING DEPARTMENT USE ONLY Check any that apply:

The above named establishment meets the requirements for Building Department approval without further action by establishment.

The above named establishment does not meet the requirements for Building Department approval. Please see attached letter

Comments: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Building Inspector Name (please print): _______________________ Title _________________ Building Inspector Signature: _______________________________________ Date: _________ Local Jurisdiction: _______________________________ Phone Number: (___)_____________

Please Remit to: Weld County Department of Public Health & Environment Attn: Environmental Health Services

1555 N. 17th Avenue Greeley, CO 80631

Phone (970) 304-6415 Fax (970) 304-6411

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SEWAGE DISPOSAL APPROVAL FORM

Body Art Establishment Name: ___________________________ Phone Number: (___)_________

Body Art Establishment Address: ________________________________________________

City: ________________________ State ________ Zip Code: ___________

Type of System: Sanitary Sewer or Individual Sewage Disposal System(ISDS) (MUST COMPLETE BACK OF FORM)

THIS SECTION FOR SEWAGE DISPOSAL OFFICALS ONLY

SANITARY SEWER:

Sanitation District: __________________________________ Installation Date: ______________

System Official (please print): _______________________________ Title _____________________

Official’s Signature: ________________________________________ Date: ___________________

THIS SECTION FOR WELD COUNTY HEALTH OFFICIALS ONLY

INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS):

Permit Name: ________________________________ Permit Number: _______________________

Is system sized correctly for intended use: ______ Yes ______ No

Official’s Signature: ____________________________Title___________________ Date: __________



Phone (970) 304-6415 Fax (970) 304-6411

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Page 2 Sewage Disposal Approval Form

INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS):

Septic System Information:

Permit Name _____________________________________ Permit Number ____________________

Last time system was pumped: _________________________ Installation Date: ________________

Was the system: Engineer Designed or Engineer Evaluated?

System Capacity: Restaurant Seats _______ Liquor License: Yes____ No _____ Bar seats _____

Grease Trap / Interceptor: Yes_____ No ______

Is system sized correctly for intended use: Yes_____ No _____

System (Owner) Official: _____________________________________ Title ___________________

Address: _______________________________________ Age of Septic System _________________

Legal: PT: ________ PT: ________ SEC: ________ TWN: ________ N RNG: ___________ W

Subdivision: __________________________ LOT: _______ BLK: ________ FLG: _____

Property Owner: ________________________________ Original Owner: ______________________

Tank Pumped on: ____________________ By: ________________ Licensed: Yes___ No ____

PERMIT ON RECORD: Name: _______________________ Permit No.: ___________ S.O.E. Y/N

Bathrooms: _______ Bedrooms: ______ Total Acres: _______ Date of Final Inspection: ________

Water Supply: ______________________________ Well Permit No.: ________________________

Tank Capacity: ________________________gallons Leachfield Size_________________ square feet

Please include a copy of the following: Pumping Receipt and Septic Permit

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WATER DEPARTMENT APPROVAL Body Art Establishment Name:___________________________________________________________ Body Art Establishment Address: _________________________________________________________ City: _____________________ State _____Zip Code: __________Phone Number: (_____)___________________

THIS SECTION FOR WATER DEPARTMENT USE ONLY What is the water source? (Please circle one) Regulated Public Water System or Unregulated Water System _____________________________________________________________________________________________ REGULATED PUBLIC WATER: Community Water System Date Connected to Source: ____________________ Name of Source: ___________________ Official’s Signature: ________________________________________ Date: _______________ Title: _______________________________________ Phone Number: (___)_______________ Non-Community Water System PWSID#: __________________

PLEASE ATTACH APPROVAL LETTER FROM STATE AS SIGNED BY DISTRICT ENGINEER UNREGULATED WATER SYSTEM: Depth of Well_____________________ What type of continuous treatment will be provided? _____________________________________________ How/where will quarterly bacteriological samples be submitted? ___________________________________ Who will be testing chlorine residual and logging results when establishment is open? __________________

PLEASE ATTACH WRITTEN COMPLIANCE PLAN

Weld County Health Dept. Water Program Manager Signature: ______________________ Date: _______________ Title: _______________________________________ Phone Number: (___) _______________

Please Remit to: Weld County Department of Public Health & Environment

Attn: Environmental Health Services 1555 N. 17th Avenue Greeley, CO 80631

Phone (970) 304-6415 Fax (970) 304-6411

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LOCAL ZONING DEPARTMENT APPROVAL

Please complete the following information and have your local zoning office representative complete the section indicated. Once the form is completed, submit to the address stated below.

Body Art Establishment Name: ________________________________________________________________ Body Art Establishment Address: _______________________________________________________________ City: _____________________ State _____Zip Code: __________________ Phone Number : (_____)________________________ Tax I.D. Number: ________________________________

THIS SECTION FOR ZONING DEPARTMENT USE ONLY Check any that apply:

The above named establishment meets the requirements for Zoning Department approval without further action by establishment.

The above named establishment does not meet the requirements for Zoning Department approval. Please see attached letter.

Comments: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Zoning Inspector Name (please print): _______________________ Title ___________________ Zoning Inspector Signature: ________________________________________ Date: _________ Local Jurisdiction: _______________________________ Phone Number: (___)_____________



Phone (970) 304-6415 Fax (970) 304-6411

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LOCAL FIRE DEPARTMENT APPROVAL

Please complete the following information and have your local fire authority representative complete the section indicated. Once the form is completed, submit to the address stated below.

Body Art Establishment Name: ________________________________________________________________ Body Art Establishment Address: _______________________________________________________________ City: _____________________ State _____Zip Code: __________________ Phone Number : (_____)__________________ Tax I.D. Number: __________________ Seating Capacity: ______

THIS SECTION TO BE COMPLETED BY FIRE DEPARTMENT

Check one of the following: The above named establishment meets the requirements for Fire Department approval without further action by

establishment. The above named establishment does not meet the requirements for Fire Department approval. Please see attached letter.

Comments: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Fire Inspector Name (please print): ________________________________ Title ____________________________ Fire Inspector Signature: _______________________________________ Date: ________________ Local Jurisdiction: _______________________________ Phone Number: (___)_____________



Phone (970) 304-6415 Fax (970) 304-6411

dear body art establishment applicant€¦ · 1. information on each employee of the body art...

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