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APPLICATION CHECKLIST New York State Department of Health Bureau of Community Environmental Health and Food Protection Tanning Facilities Program This checklist is to ensure that each application includes the required forms and fee, and to remind applicants of State Sanitary Code Subpart 72-1 requirements. Subpart 72-1, required forms, and other important information can be found at: http://www.health.ny.gov/environmental/indoors/tanning/ Submit this checklist with your application Facility Name/DBA: Facility Address: County: City/Town/Village: Name of Operator or Legal Entity: Check the following items to attest that it is included in your application ☐ Application for a Permit to Operate (DOH-3915) ☐ NYS Workers’ Compensation and Disability Insurance forms; correct forms and numbers are listed on the application for a Permit to Operate ☐ Tanning Facility Fee Determination Schedule ☐ Check payable to New York State Department of Health Check the following items to attest that you comply with these requirements of Subpart 72-1 ☐ Warning Sign (11 X 17 inches) posted within 3 feet of each device ☐ Tanning Hazards Information Sheet provided to each new patron ☐ Statement of Acknowledgement Form signed by operator and patron and kept on site ☐ Required FDA labels affixed on all approved UV tanning devices (21CFR 1040.20) ☐ Remote timer control and lockout equipment for each UV tanning device ☐ Proof of UV lamp compatibility for each UV tanning device Operator Signature: Date: Print Name: