Skin penetration/beauty/hair business registration - V1 - January 2018

Skin penetration/beauty/hair business registration Public Health Act 2010, Public Health Regulation 2012

Business address

Business name

Business details

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EmailMobilePhone

Waxing

Residential address

SurnameGiven name/s

Procedures conducted (please select)Acupuncture

Beauty therapy Tattooing

Electrolysis

Manicure

Pedicure

Hairdressing only

Body piercing Ear piercing

Blood testing

Colonic lavage

Cosmetic tattooing

Other

Registration number

Office use only

Entered

EmailMobilePhone

ABN (if any) ACN (if any)

Proprietor 1 details

Phone Mobile Email

Residential address

SurnameGiven name/s

Proprietor 2 details

Council collects business details in accordance with the notification of carrying out of skin penetration procedures requirements of the Public Health Act 2010 and Public Health Regulation 2012. Council requires proprietor and business details to register your business. This form is to be used if you are starting a new business, taking over an existing business or changing the details of a current business.

Skin penetration/beauty/hair business registration - V1 - January 2018

Forster | 4 Breese Parade | PO Box 450 Forster 2428 | 6591 7222

Gloucester | 89 King Street | PO Box 11 Gloucester 2422 | 6538 5250 Taree | 2 Pulteney Street | PO Box 482 Taree 2430 | 6592 5399

www.midcoast.nsw.gov.au

Privacy: This information is required to process your request and will not be used for any other purpose without seeking your consent, or as required by law. Your application will be retained in Council's Records Management System and disposed of in accordance with current legislation. Your personal information can be accessed and corrected at any time by contacting Council.

Completed form can be: • Emailed (select the submit buttom below); or • Forwarded by post; or • Lodged at our Customer Service Counter - Monday to Friday (excluding Public Holidays).

How to lodge this form

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Proprietor's signature (if submitting electronically, print name) Date

DateProprietor's signature (if submitting electronically, print name)

· I/we hereby provide information to Council for registration of a skin penetration/beauty/hairdressing business in the MidCoast Council area.

· I/we understand that the business will be subject to regular health inspections by Council's authorised officers. · I/we understand Council must be notified within seven (7) days of any change in the particulars provided above. · I/we confirm that the above particulars are true and correct.

Declaration and signature of applicant