(LONDON) INKED CIRCUS PUBLIC HEALTH FORM.

INKED CIRCUS PUBLIC HEALTH FORM.

This form is to assist in the collection of information required for Middlesex-London Health Unit. For the Inked Circus expo. Although Inked Circus will collect as much information as possible, it is aware and making aware its Artists that additional information may be request from the health board and 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.
Shop Name:*
Shops Main Contact Name for the Health Board.*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
EVENT NAME: INKED CIRCUS TATTOO EXPOS

- Inked Circus London
EVENT VENUES / DATES:

August 16-18th, 2024: London, Ontario: Budweiser Gardens - 99 Dundas St, London, Ontario Canada N6A 6K1
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. *
Name, The Type of Service, Their Title
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, please name the Public Health Unit, date of inspection and attach a copy of your latest inspection report. Which health unit are you inspected by?*
If no, where would all of your instruments/equipment be reprocessed?*
All Artists have been made aware that there is no Autoclaving allowed during the event onsite.
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.
Cancelof
What Are the Services Being Performed In Your Booth:*

TattooingBody PiercingHair (PMU)Tooth GemsBody Modifications
List and number of instruments/equipment that you will bring (e.g., 10 forceps, 50 needles, personal protective equipment?) for each service. Please attach additional pages if you require more space to list all the instruments/equipment that you will be bringing. NOTE: You must bring enough instruments for use to ensure that services can be provided with clean and disinfected instruments to each client.*
Please List Items with Qty's
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 etc.)

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 and sterile, provide the name/address/telephone number of the supplier(s).
Supply Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid 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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
CLEANING AND DISINFECTION OF EQUIPMENT AND SUPPLIES
Although it is important to note here that Inked Circus Tattoo Expos goes above and beyond to make sure that Artists are supplied with many things, we would like to clarify here that these things include:

- 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/supplieswill 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/NPNTest strips for the disinfectant(sN/A
HAND HYGIENE

What type of handwashing station
(with hot and cold running water,
liquid soap, and paper towels) will
be provided in the service area?
Please note it is to be used for
handwashing only.

Answer: Yes – Portable handwashing station provided by organizer/vendor. Provide
details on disposal of wastewater from the portable sink(s)

Artists Are Aware That The Supply of 70% alcohol-based hand rub at each service area. This
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)
Date

MonthDayYear
Date
Name

First NameLast Name
Signature

Clear
Should be Empty:

INKED CIRCUS PUBLIC HEALTH FORM.

SPECIAL EVENT REQUIREMENTS FOR PERSONAL SERVICES VENDORS

EVENT NAME: INKED CIRCUS TATTOO EXPOS

PROOF OF PUBLIC HEALTH INSPECTION:

For items purchased pre-packaged and sterile, provide the name/address/telephone number of the supplier(s).

For items sterilized at a business location, provide the name and address of where the items were sterilized, if different from above.

CLEANING AND DISINFECTION OF EQUIPMENT AND SUPPLIES