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London · Public Health

Inked Circus Public Health Form

This form assists in collecting information required for Middlesex-London Health Unit. Although Inked Circus will collect as much information as possible, it is aware that additional information may be requested from the health board. Artists may be contacted or additional information may be requested at the time of inspection at the shows.

Special Event Requirements for Personal Services Vendors

All vendors MUST submit a completed Vendor Application Form at least 30 days prior to the start of the event.

▪ If Vendor Application Event Forms have not been received at least 30 days prior to the event, there may not be adequate time to review and approve the vendor prior to the event.

▪ Vendors must comply with the Special Event Guidelines For Personal Services and with applicable sections of the Personal Service Settings Regulation 136/18, under the Health Protection and Promotion Act, R.S.O., 1990.

▪ A Public Health Inspector will contact you prior to the event to discuss your application.

Vendor / Shop Information

Shop Name*

Shop's Main Contact Name for the Health Board*

Email*

Address*

Phone Number*

Event Name: Inked Circus Tattoo Expos

Event Venues / Dates:

London, Ontario: the J-AAR EXPO CENTRE (Formerly, The Agriplex) - 316 Rectory Street, London, Ontario Canada N5W 3V9

Which Stops On The Tour Are You Attending?*

London, Ontario (Middlesex-London Health Unit)

Will You Be Applying For Inspection For Yourself or All Members Of Your Booth (under 1 Inspection)?*

Just for MyselfFor All Artists Within Our Booth

How Many Artists Will Be In Your Booth In: London

Please List The Names Of The Artists Providing Services In Your Booth*

Proof of Public Health Inspection (At Your Current Shop / Studio)

Have you been inspected by A Public Health Unit In Your Region?*

YesNoWe do not have a Public Health Inspection where we're located.

If yes, which health unit are you inspected by?

If no, where would all of your instruments/equipment be reprocessed?

Please Upload A Copy Of Your Region's Health Board Inspection Pass

If your Region, Province, or Country does not have these passes, please skip.

Browse or drag file here

Services & Equipment

List and number of instruments/equipment that you will bring*

Critical Items / Equipment Used On-Site

All items/equipment that require sterilization such as needles, needle bars, jewellery, and forceps that are brought to the venue must be purchased pre-packaged, sterile and labelled with lot numbers and expiry dates.

Ensuring Needle Cartridges used for tattooing are equipped with backflow prevention (aka safety membrane) to prevent ink/fluid ingress into the machine body.

Critical items/equipment that are packaged and sterilized at an inspected facility must be labelled with date of sterilization and accompanied by copies of the last 3 spore test results from the sterilizer(s)/autoclave(s) used for sterilization. Spore tests results must be in English.

Sterilization of items is NOT ALLOWED on-site at the event.

Will critical items be used on-site?*

YESNO

For Items Purchased Pre-Packaged & Sterile — Supplier Details

Supply Company*

Address*

Phone Number*

For Items Sterilized at a Business Location

Provide the name and address of where the items were sterilized, if different from above. Copies of the last 3 spore test results must be on-site from the sterilizer(s)/autoclave(s) used for sterilization. Spore tests results must be in English.

Company Name

Address

Phone Number

Cleaning & Disinfection of Equipment and Supplies

Inked Circus Provides:

— Waste Bin

— Garbage Bags & Collection

SHARPS: YES. A CSA-approved sharps containers are provided and disposed of by the event organizer. They are kept safe in the Artist's Booths over the 3-day event and collected at the end of the show after the public has left the building, and taken to the disposal site within the region.

— Sharp's Containers Provided, Collected, and Disposed of.

— 70% Isopropyl Alcohol

— MinuteMan Disinfectant Wipes (We ask Artists to bring Wipes vs Spray if bringing their own to keep the particles contained)

— Hand Sanitizer

What type of equipment/supplies will you bring on-site? (check all that apply)*

Provided By Venue - Reprocessing sink (large enough to submerge largest piece of equipment that requires cleaning and disinfection on-site). Must be plumbed in.BrushesDetergentDisinfectant(s) (specify name/type and DIN/NPN)Test strips for the disinfectant(s)N/A

Hand Hygiene

Answer: Yes – Portable handwashing station provided by organizer/vendor.

Artists Are Aware That The Supply of 70% alcohol-based hand rub at each service area does NOT replace the need for a dedicated handwashing station.

Inked Circus Will Provide The NPN / DIN and Expiration Date of all Supplied Products. If an Artist brings their own, they will provide it for inspection within their booth and are aware that every bottle requires an NPN / DIN #.

Booth Layout Description

Each Artist has either an 8'x8' Single Artist Space or Sharing space with another Artist within a 10'x10' Space.

Within the space is:

1. 6ft Display Table 2. Folding Chairs 3. 1-2 Massage Tables 4. 1-2 Artist Stools 5. 1-2 Work Surfaces (Usually consisting of a Medical Mayo Tray or Small Tool Box)

Declaration & Signature

Date*

Name*

Signature*