Skin piercing registration application form

Application for Registration in respect of Acupuncture, Tattooing, Cosmetic Piercing, Electrolysis and Semi-Permanent Skin Colouring
1. Local Government (Miscellaneous Provisions) Act 1982
  SECTIONS 14 and 15
2. There is a registration fee payable.
  Details of the fee can be found on our Skin Piercing page.
  Payment can be made by debit or credit card by telephoning 01362 656870 .
  If you are unable to pay by debit or credit card, please email foodandsafety@breckland.gov.uk to discuss alternative methods of payment.
3. Fields marked with * are required
4. I hereby apply for registration to:*
  
  Practice Acupuncture
  
  Carry on the Business of Tattooing
  
  Carry on the Business of Cosmetic Piercing
  
  Carry on the Business of Electrolysis
  
  Carry on the Business of Semi-Permanent Skin Colouring
5. Applicant Name*
6. Trading Name of Business*
7. Address (for correspondence)*
8. Email*
9. Telephone No*
10. Address of premises at which practice or business will be carried out (if different from above)
IMPORTANT: Please provide details of the name(s) of each employee of the business and the registered treatment(s) they are competent to offer as operators
This person/these persons will appear on the Registration Certificate as named operators

Remember to include your name as the applicant and any treatments you personally wish to undertake (if relevant)
The treatments are Acupuncture, Tattooing, Cosmetic Piercing, Electrolysis, Semi-Permanent Skin Colouring, please enter all the treatments being undertaken in the box below
Operator details
1. Name of Operator in full*
2. Treatment(s) undertaken*
Operator details
1. Name of Operator in full
2. Treatment(s) undertaken
Operator details
1. Name of Operator in full
2. Treatment(s) undertaken
Operator details
1. Name of Operator in full
2. Treatment(s) undertaken
Operator details
1. Name of Operator in full
2. Treatment(s) undertaken
Operator details
1. Name of Operator in full
2. Treatment(s) undertaken
Please be aware that, if required to do so, you should be able to demonstrate that each of the person(s) listed above has attended appropriate training to be competent to offer such treatments to your clients.
Declaration details
1. Have you, or to the best of your knowledge, any person who will be engaged in your practice or business
2. a) been convicted within the previous five years of carrying on the practice or business which is the subject of your application without being registered by a local authority under this Act;
3. Question A answer*
  
  Yes
  
  No
4. b) been convicted within the previous five years of carrying on the practice or business which is the subject of your application in premises which were not registered by a local authority under this Act;
5. Question B answer*
  
  Yes
  
  No
6. c) had a registration under this Act suspended or cancelled by order of a court;
7. Question C answer*
  
  Yes
  
  No
8. I understand that by checking the declaration box it is classed as my electronic signature and is the legally binding equivalent to my handwritten signature. Furthermore, I declare that I have read and understood the Skin Piercing Registration Application notes relating to this application
9. Signature
10. Name of person completing the form*
Privacy statement

Breckland Council is collecting this information, via this form, in order to perform this service or function, and if further information is needed in order to do so, you may be contacted using the details provided.
In performing this service, the council may share your information with other organisations or departments, but only when it is satisfied that it is necessary to perform a public task, or to exercise its statutory duties to do so.
The council may also share your personal information for the purposes of the prevention, investigation, detection, or prosecution of criminal offences. However, it will not share your personal information, or use it for any other purpose, unless provided for by law.
More detailed information about the council's handling of your personal data can be found in our privacy policy.

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Skin piercing registration application form

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Skin piercing registration application form

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