NEHA Annex to the Body Art Model Code, 3rd Edition

August 2025. Published by the National Environmental Health Association (NEHA), www.neha.org.

3rd Edition August 2025

Annex to the Body Art Model Code

Forward Annex to the 2024 Body Art Model Code, 3rd Edition

This Annex is provided as a supplement to the Body Art Model Code (the Code). It offers scientific justification and rationale to support the requirements outlined in the Code, but it is not intended to be interpreted or enforced as additional Code requirements. The purpose of this Annex is to help users better understand the content and intent of the Code and to support its effective implementation. It is designed to assist health departments, body art regulators,

body artists, and other stakeholders in promoting the health and safety of body art establishments and procedures. This Annex does not intend to provide any medical advice or diagnoses. Unless separately licensed, body artists are not medical professionals and should not give, or be perceived as giving, medical advice or diagnoses.

Acknowledgements NEHA Body Committee Members

John Johnson Body Piercer & Owner of New Flower Studio Body Piercing OSHA Authorized General Industry Trainer Association of Professional Piercers (APP)

Amy Ward Tattoo Artist & Owner of A-ok Tattoo

Joseph “Austin” Addison DHSc, REHS, CHES Environmental Health Specialist IV NEHA Body Art Committee Regulatory Chair Georgia Department of Public Health Benjamin Shaw Tattoo Artist & Owner of Archetype Tattoo Alliance of Professional Tattooists

Katherine Martinez, REHS Sanitarian Specialist Kent County Health Department

Kathy Hartman, REHS OSHA Authorized General Industry Trainer Body Art Training Group President

Brian Everett Tattoo Artist

Kenya Urena-Muro, REHS Health Inspector II

Cathy Montie Tattoo Artist Founder & Owner - Cathy Montie Body Art Training Company OSHA Authorized Industry-Specific Trainer David Wagoner, REHS Sanitarian II Calhoun County Public Health Department Denice Rimple, MPH, REHS, LPN Senior Registered Environmental Health Specialist Lead Inspector Risk Assessor

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Kira Flagstead Dierickx, REHS/RS Public Health Sanitarian Montana DPHHS

Kristina Wright Owner of United Tattoo

Laurel Arrigona Smith + Nephew Regulatory Affairs Manager AFDO Body Art Committee Leslie Ossai, REHS CA Body Art Technical Advisory Committee Lindsey Strong, REHS Casper-Natrona County Health Department

Eddie Murphy Health Coordinator/Inspector Tattoo Artist

Heather Woods, REHS Sr. Environmental Health Specialist Southern Nevada Health District Special Programs James Wisdom Tattoo Artist & Owner of Tattooing Wisdom Alliance of Professional Tattooists Jodi Jackson, REHS, MPH Registered Environmental Health Specialist II Grand County Public Health

Macdonald Aloh, MBBS, MPH Environmental Health Specialist

Maria Deaver Senior REHS Body Art & Ear-Piercing Program Coordinator Burlington County Health Department

Maria Vega Environmental Health Specialist

Acknowledgements NEHA Body Committee Members

Vildana Tinjic, CP-FS, CPO, PCQI, HACCP certified, RN Senior Environmental Health Specialist Tattoo Program Lead Linn County Public Health Wendy Maurer, RS, REHS Coconino County Health & Human Services

Matt Bavougian Body Art Compliance Onyx Piercing Studio

Michael Crea, R.S. Owner of Z-Edge Piercing Inc. Executive Director of FEHA Body Art Industry Educator & Private Consultant

Nathan M. Daily, RRT Senior Sanitarian Allegheny County Health Department

NEHA Staff

Christl Tate Associate Director, Programs

Robin Hays Cosmetic Tattoo Artist Owner of About Face Inc. Society of Permanent Cosmetic Professionals Past Board Member

Sadie Shervheim Project Coordinator

Rufus Redsell, MPH Environmental Health Officer Runnymede Borough Council

Sarah Badenhop, REHS Public Health Environmental Health Specialist II Steve Joyner Body Art Professional Body Art Compliance Co-Founder Body Art Alliance, Regulatory & Compliance Suzanne Fajgier, REHS, CPH, CP-FS, CFOI Principal Registered Environmental Health Specialist Burlington County Health Department Tyson Schaffert Tattoo artist NEHA Body Art Committee Industry Chair Alliance of Professional Tattooists Representative and Board of Directors

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Contents

Definitions Body Art Operator Requirements and Professional Standards 02 Jewelry Standards Specific Regulations for Specific Types of Body Art 04 03

PAGE 01

PAGE 09

PAGE 12

PAGE 13

Public Notification Requirements Facility Documentation Requirements 06

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08 07 09 10 12 11 13 14 18 17 19 20 16 15 21

Informed Consent and Release Form

PAGE 21

Disinfection and Sterilization Procedures

PAGE 22

Preparation and Care of the Procedure Site

PAGE 24

Requirements for Single-Use Items

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Regulated Waste

PAGE 26

Requirements for Premises

PAGE 31

License Requirements

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Prohibitions

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Enforcement

PAGE 40

Inspection

PAGE 40

Suspension

PAGE 41

Revocation

PAGE 41

Citations

PAGE 42

Department Personnel Competancy Requirements

PAGE 42

Interpretation and Severability

PAGE 43

Appendicies

PAGE 44

Appendix A: NEHA Policy Statement on Ear Piercing Guns

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Appendix B: NEHA Policy Statement on Microblading

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Appendix C: U.S. EPA Registered Antimicrobial Products Effective Against Mycobacterium tuberculosis (TB)

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Appendix D: Waste Definitions and Regulated Waste Flow Chart

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References

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1. Definitions The terms used in this Code and Annex are defined as follows:

AFTERCARE means suggested instructions given to the client, specific to the body art procedure(s) rendered, about caring for the body art and surrounding area. These instructions will include information about when to seek medical treatment, if necessary. ANTISEPTIC means a product that is labeled as useful in preventing diseases caused by microorganisms present on the skin and/or mucosal surfaces of humans. This includes products meant to kill germs and/or labeled as “antiseptic,” “antimicrobial,” “antibacterial,” “microbicide,” or “germicide,” or other similar terms. ASEPTIC technique means a set of specific practices and procedures performed under controlled conditions with the goal of minimizing contamination by pathogens. AUTHORIZED AGENT means an employee of the designated health department/district charged with the enforcement of this Code.

AUTOCLAVE means a piece of equipment that is intended to sterilize products by means of pressurized steam.

AUTOMATED INSTRUMENT WASHER means a mechanical washer designed specifically for the decontamination of instruments prior to sterilization.

BIOCOMPATIBLE means the ability of an object to be inserted into a person without eliciting any undesirable local or systemic effects in that person.

BIOHAZARDOUS WASTE means any solid or liquid waste that can present a threat of infection to humans, including body tissue, blood and bodily fluids, wastes that contain blood or other potentially infectious material (OPIM). This includes, but is not limited to, absorbent materials with blood, bodily fluids, or excretions/secretions; and other contaminated products used during a body art procedure. BLOODBORNE PATHOGEN means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

BODY ART means body piercing, tattooing, branding, scarification, or cosmetic tattooing.

BODY ART ESTABLISHMENT means any place or premise, whether licensed or not, public or private, temporary or permanent, outside or inside, for profit or not, where the practices of body art are performed.

BODY ARTIST means any person performing body art services, whether licensed or not.

BODY PIERCING means any method of piercing the skin or mucosa to place jewelry through the skin or mucosa. BRANDING means the process in which a mark or marks are burned into human skin tissue with the intention of leaving a permanent mark. CAS REGISTRY NUMBER also referred to as CASRN or CAS Number, means a unique numerical identifier assigned by the Chemical Abstracts Service (CAS) to every chemical substance described in the open scientific literature.

CHRONIC/REPEAT VIOLATIONS means a violation that has occurred three times within five inspections.

CLIENT means an individual upon whom a body artist performs a body art procedure.

CODE means this document, as amended, and any supporting documents specifically incorporated herein.

COMPLAINT OF INJURY FORM means a document used to file with the Department a notice of injury as a result of a body art procedure.

CONTAMINATED means the presence or the reasonably anticipated presence of blood or OPIM on an item or surface.

COSMETIC TATTOOING see TATTOOING

CRITICAL VIOLATIONS means those items that are likely to cause an imminent health hazard to the public and/or body artist.

CYCLE NUMBER means a unique number that corresponds to each individual autoclave cycle. This number is used as an identifier, sometimes known as a lot number. It may include the date as part of the number. DECONTAMINATION means the use of physical and/or chemical means to remove, inactivate, or destroy pathogens on a surface. A surface/item is decontaminated when there are no infectious particles, and then the surface/item is rendered safe for handling, use, or disposal.

DEPARTMENT means the agency (whether local, state, or federal) or its authorized representatives who have jurisdiction to promulgate, monitor, administer, and enforce regulations.

DISINFECTANT means a product that is tuberculocidal and registered by the U.S. Environmental Protection Agency (EPA), as indicated on the label for use in disinfection.

DISINFECT means to destroy pathogenic and other kinds of microorganisms by physical and/or chemical means. DIVIDER means a partition used to separate or delineate a workstation from other workstations, such as non-absorbent curtains, knee walls, or other hard partitions.

EAR PIERCING see BODY PIERCING

EAR-PIERCING GUN means a stud-and-clasp ear-piercing system.

ENZYMATIC cleaning solution means a cleaner that relies on biological catalysts to remove proteins or biofilms from a surface. EQUIPMENT means all machinery, containers, vessels, implements, storage areas, and sinks that are used in conjunction with the storage or application of body art, by a body artist, or used within the sterilization/decontamination and disinfection processes.

FACILITY see BODY ART ESTABLISHMENT

FURNISHINGS means all fixtures, furniture, and other objects within a body art establishment that are not integral to the structure of the physical establishment (e.g., walls, windows, doors) and are not used in the storage of body art equipment and instruments, application of body art, or its sterilization/ decontamination and disinfection processes. GLOVES means medical grade or exam grade, sterile or nonsterile, disposable, single-use, full-hand coverings worn for protection against disease transmission. GUARDIAN means a person lawfully invested with the power and charged with the obligation of taking care of managing the property and rights of a person who, because of age, understanding, or self-control, is considered incapable of administering his or her own affairs. HAND WASHING means the act of cleaning one’s hands for the purpose of removing dirt, soil, or microorganisms through the use of soap, warm water, and friction. HAND WASHING SINK means a sink equipped to provide water at a temperature of at least 38°C (100°F) through a mixing valve or combination faucet, used solely for washing hands, arms, or prosthetics.

IDENTIFICATION means a government-issued ID card with name, photo, and birthdate.

IMMINENT HEALTH HAZARD means a significant threat or danger to health that is considered to exist when there is evidence sufficient to show that a product, practice, circumstance, or event creates a situation that requires immediate correction.

INDICATOR means a test or device designed to validate one or more of the following critical variables of an autoclave cycle: time, temperature, and steam/pressure. The three types of indicators are chemical, biological, and mechanical. CHEMICAL INDICATOR means a substance that undergoes a distinct observable change when conditions in its solution change while measuring the sterilization process. This could be a color change, precipitate formation, or bubble formation, in order to show a temperature change, or other measurable quality. BIOLOGICAL INDICATOR (BI) means a test system containing viable microorganisms (spores) providing a defined resistance to a specific sterilization process. A biological indicator provides information on whether necessary conditions were met to kill a specified number of microorganisms for a given sterilization process.

MECHANICAL INDICATOR means a self-recording gauge used to verify the time, pressure and/or temperature obtained during the sterilization process.

INFORMED CONSENT AND RELEASE FORM means a form signed by a client prior to a body art procedure to confirm that they agree to the procedure and are aware of any risks that might be involved.

INITIAL PIERCING means a fresh or new body piercing.

INSPECTION means a careful examination, exploration, or evaluation of the body art establishment and the body artist by the Department in compliance with this Code. INSTRUMENTS/TOOLS/DEVICES/IMPLEMENTS USED FOR BODY ART means handpieces, needles, needle bars, tattoo machines, forceps, and other tools that could come in contact with a client’s body or could be exposed to bodily fluids during body art procedures. INTEGRATOR also referred to as Type 5 Integrator or an Integrating Indicator, means a device designed to validate all three of the following critical variables of an autoclave cycle: time, temperature, and steam under pressure.

JEWELRY means any biocompatible object that is worn through a body piercing.

LICENSE means written approval by the Department to operate a body art establishment or to perform body art. Approval is given in accordance with this Code and in addition to any other local, state, or federal requirements.

MAINTENANCE means repairs and upkeep of equipment as recommended by the manufacturer.

MATERIAL CERTIFICATE means all documents intended to state the specifics of a material used for body jewelry. Names for these documents include but are not limited to Mill Certificates, Material Certificates, Metal Composition Sheets, Material Safety Data Sheets (MSDS), and Material Certification Sheets.

MICROBLADING see TATTOOING

MINOR means an individual under the age of eighteen (18) years.

MOBILE BODY ART ESTABLISHMENT/UNIT means a licensed mobile establishment or unit that is self-propelled or otherwise movable from place to place and operated by a licensed body artist who performs body art procedures.

MUCOSA see MUCOSAL SURFACE

MUCOSAL SURFACE means the moisture-secreting membrane lining of all body cavities or passages that communicate with the exterior, including but not limited to the nose, mouth, vulva, and urethra. MUNICIPAL SOLID WASTE means common trash or garbage that does not meet the definition of regulated waste. NONCRITICAL VIOLATIONS means those items are not likely to cause an imminent health danger to the public and/or the practitioner. OPERATOR means any person, whether permitted or not, who controls any interest in, operates, or manages a body art establishment and who is responsible for compliance with this Code, whether or not actually performing body art activities. OTHER POTENTIALLY INFECTIOUS MATERIAL (OPIM) means: 1. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; 2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and 3. HIV-containing cell or tissue cultures, organ cultures, HIV- or HBV-containing culture medium or other solutions, blood, organs, or other tissues from experimental animals infected with HIV, HVC, or HBV.

PERMANENT COSMETICS see TATTOOING

PERMIT see LICENSE

PERSON means an individual, any form of business or social organization, or any other non- governmental legal entity, including but not limited to corporations, partnerships, limited liability companies, associations, trusts, or unincorporated organizations. PERSONNEL means employees, body artists, contracted body artists, and agents of the body art facility, whether or not actually performing body art activities. PHYSICIAN means a person licensed by the state to practice medicine in all its branches and may include other areas such as dentistry, osteopathy, or acupuncture, depending on the rules and regulations particular to that state.

PROCEDURE means the act of performing body art.

PROCEDURE AREA means a room, or portion of a room, or any surface of an inanimate object that is designated to be used only to perform body art.

PROCEDURE SITE means the area or location on the client’s body selected for the placement of body art.

PROPYLENE GAS means any gas that is labeled with a CAS Registry Number of 115-07-1 (this includes but is not limited to MAPP gas and methyl ethylene gas).

REGULATED WASTE means liquid or semi-liquid blood; items contaminated with blood or OPIM, and which would release these substances if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; and contaminated sharps containing blood or OPIM. REGULATED WASTE OPERATING PLAN means a document detailing policies and procedures regarding the containment, labeling, storage, and transport of biomedical waste, in addition to detailed training for personnel of the body art establishment. SAFETY DATA SHEET (SDS) means a document for any potentially harmful chemical that includes information such as the properties of each chemical; the physical hazards, health hazards, and environmental health hazards; protective measures; and safety precautions for handling, storing, and transporting the chemical. SDS is the current term for Material Safety Data Sheet (MSDS).

SCALP MICROPIGMENTATION (SMP) see TATTOOING

SCARIFICATION means the process in which a mark or marks are cut into human skin tissue with the intention of leaving a permanent mark.

SEMIPERMANENT MAKEUP see TATTOOING

SHARPS means any object that can purposely or accidentally cut or penetrate the skin or mucosa, including but not limited to presterilized, single-use needles; scalpel blades; and razor blades.

SHARPS CONTAINER means a closable, puncture-resistant, leakproof (on sides and bottom) container made specifically to be a sharps container that can be closed for handling, storage, transportation, and disposal. A sharps container must be labeled with the international biohazard symbol. SINGLE-USE means products or items that are intended for one-time, one-person use and are disposed of after use on each client, including but not limited to cotton swabs or cotton balls, tissues or paper products, paper or plastic cups, gauze and sanitary coverings, razors, needles, scalpel blades, stencils, ink cups, and protective gloves.

SPORE TEST see INDICATOR – BIOLOGICAL INDICATOR

STANDARD OPERATING PROCEDURE (SOP) means an instructional document that describes all procedures and processes that are to be followed step-by-step, by each worker in a facility, so as to produce the exact same results safely no matter who performs routine operations.

STERILIZATION means a validated process used to render a product free from viable microorganisms.

STERILIZATION AREA or STERILIZATION ROOM means a room or enclosed area, set apart and used only to clean, decontaminate, and sterilize instruments. STERILIZATION LOG means a physical or digital recording of autoclave cycle number, as well as type of sterilizer and cycle used; the load identification number; the load contents; the exposure parameters (e.g., time and temperature); the operator’s name or initials; date and time; and the results of mechanical, chemical, and/or biological monitoring. STRIKE BRANDING means the process by which a mark is burned with heated metal into the tissue of a person. STERILE GLOVES means a medical-grade or exam-grade disposable, single-use covering for the hands worn for protection against disease transmission. Sterile gloves have been sterilized by the manufacturer or by following the sterilization protocol set forth by the glove manufacturer.

STERILE WATER means water that is purchased from the manufacturer sterile, in a single-use container.

STERILE means a state of being free from viable microorganisms.

TATTOO means the mark resulting from the act of tattooing.

TATTOOING means any act of placing ink or other pigment into or under the skin or mucosa by the use of needles or any other method used to puncture the skin, resulting in permanent or temporary colorization of the skin or mucosa. This includes all forms of cosmetic tattooing performed on the face or body.

TEMPORARY BODY ART ESTABLISHMENT means any place or premise operating at a fixed location where a body artist performs body art procedures but does not have a permanent body art facility license (i.e., educational, trade show, convention, public or private events, performance, product demonstration, or aesthetic shows).

TEMPORARY BODY ARTIST LICENSE see LICENSE

THERMAL CAUTERY UNIT (TCU) means electrical equipment that provides direct or alternating current that is passed through a resistant metal wire electrode, generating heat used for branding.

TYPE 5 INDICATOR see INTEGRATOR

ULTRASONIC CLEANER or ULTRASONIC means equipment that removes debris by a process called cavitation, in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces. ULTRAVIOLET AIR PURIFIER means a machine designed to use short wave ultraviolet (UV-C) light to inactivate airborne pathogens and microorganisms.

VIOLATION means the act of violating or going against any section or subsection of this Code.

WORKSTATION means the area within a procedure area where a body artist performs body art. The workstation includes but is not limited to the client chair or table, counter, mayo stand, instrument tray, storage drawer, and practitioner’s chair.

2. Body Art Operator Requirements and Professional Standards

2.1 The Centers for Disease Control and Prevention (CDC) determined that the use of ASEPTIC TECHNIQUE is a fundamental standard of care to prevent infection in healthcare settings. This standard is “not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices” (Healthcare Infection Control Practices Advisory Committee, 2017). The Body Art Committee (BAC) recognizes that not all policies and procedures required for a healthcare setting or laboratory are applicable to a BODY ART ESTABLISHMENT but believes that due to the nature of the work and the severe risk for transmission of harmful pathogens via body fluids, ASEPTIC TECHNIQUE is an important standard for BODY ART ESTABLISHMENTS. 2.2 The U.S. Department of Labor classifies MINORS as individuals under the age of 18 (U.S. DOL, n.d.). The Fair Labor Standards Act (FLSA) sets standards and requirements for MINORS working in jobs covered by the statute and dictates permitted occupations for MINORS, abiding by the guiding principle that the working conditions do not interfere with their schooling or health and well-being. As applicable to BODY ART, 29 C.F.R. 570.34(b) permits 14- and 15-year-olds to be employed to perform work of an artistically creative nature (U.S. DOL, 2016). U.S. DOL does not, however, consider TATTOOING or BODY PIERCING to be artistically creative endeavors under the provisions of either 29 C.F.R. 570.34(b) or 29 C.F.R. 541.302(b) due to the potential for exposure to BLOODBORNE PATHOGENS (Child Labor Regulations, 2010). Where state employment law and the FLSA overlap, whichever law is more protective of the MINOR shall be applied (U.S. DOL, n.d.). 2.3 BODY ARTISTS and ESTABLISHMENTS must have a current applicable state, county, or city license, permit, and/or other regulatory requirements per Section 13 of this Code to ensure the BODY ART ESTABLISHMENTS are properly inspected and regulated in the interest of PERSONNEL and CLIENT safety. 2.4 BODY ARTISTS must maintain a certain level of personal hygiene to avoid contaminating their WORKSTATION and INSTRUMENTS. Relative to other parts of the hand, the area underneath the fingernails harbors the most microorganisms and is the most difficult area to clean (Lin et al., 2003). Artificial, or acrylic, nails harbor more bacteria than natural nails and as such, this Code prohibits BODY ARTISTS from wearing them. According to the Association of Perioperative Registered Nurses (2021), “Artificial nails have been associated with hand contamination and epidemiologically implicated in outbreaks caused by gram-negative bacteria and yeasts.” Fingernail length is another essential element in hand hygiene, as studies have consistently found that microbial cell numbers are positively correlated with fingernail length (Lin et al., 2003; Wu & Lipner, 2020). As of publication, no studies have shown that nails with intact polish harbor more microbes than unpolished nails. Studies have found, however, that nails with chipped polish might serve as reservoirs for microbes (Ward, 2007).

2.5 Open, uncovered wounds are entry points for pathogens (Mckenzie, 2018). Infections can spread through contact, sprays and splashes, inhalation, and punctures (CDC, 2016). The BODY ARTIST must treat and cover any wounds, infections, or communicable diseases to prevent infection and the spread of disease. 2.6 This Code requires PERSONNEL to remove all jewelry on hands and wrists when preparing for and during a PROCEDURE. Several studies have found that skin underneath jewelry harbors more bacteria than comparable areas of skin without jewelry (CDC, 2002). Studies suggest that neither soap nor hand sanitizer can adequately remove bacteria from under jewelry and jewelry should be removed for proper hand hygiene (Greenshield et al., 2020). 2.7 Proper HANDWASHING can stop the spread of communicable diseases. CDC guidelines for HANDWASHING recommend HANDWASHING prior to a BODY ART PROCEDURE, after any interruption during a PROCEDURE, prior to putting on GLOVES, and upon completing a PROCEDURE. Ensuring active participation of PERSONNEL in proper hand hygiene practices depends upon facilitators at various levels (CDC, 2002). The Occupational Safety and Health Administration (OSHA) requires that employers provide handwashing facilities that are readily accessible to employees (Bloodborne Pathogens, 2012). Beyond providing the physical resources to maintain proper hand hygiene, the Body Art Committee encourages stakeholders to foster a culture of hand hygiene adherence and promotion. Hands of BODY ART PERSONNEL can transmit pathogens if proper hand hygiene is not performed. This Code requires PERSONNEL to follow a HANDWASHING procedure to reduce the potential for infection. This Code requires PERSONNEL to wash hands with clean, running water, as hands can become recontaminated if placed in a basin of water that has been CONTAMINATED through previous use (Palit et al., 2012). Hands must be lathered to create friction, which helps lift debris and microbes from the skin. The entire hand must be scrubbed, as microbes are present on all surfaces of the hand and are highly concentrated under the nails (Lin et al., 2003). Proper handwashing technique as dictated by the CDC’s procedure requires hands to be scrubbed for at least 20 seconds (CDC, 2022). PERSONNEL should point their fingers toward the faucet when rinsing their hands to avoid recontaminating their hands with anything from their upper arms. Hand drying is an essential part of hand hygiene, as bacteria are more likely to be transmitted from wet skin than from dry skin (Huang et al., 2012). A systematic literature review of twelve studies on hand drying effectiveness found that SINGLE-USE paper towels efficiently dry hands, effectively remove bacteria, and cause less CONTAMINATION of the surrounding washroom environment than electric air dryers. The review concluded that SINGLE-USE paper towels should be used “in locations where hygiene is paramount” (Huang et al., 2012). 2.8 PERSONNEL must make their best efforts to prevent CONTAMINATION of EQUIPMENT. As stated in Section 2.1 of this Code, BODY ARTISTS must use ASEPTIC TECHNIQUE. To prevent CONTAMINATION of EQUIPMENT surfaces that are difficult to clean, barriers such as clip cord covers and machine covers can be used (CDC, 2019a).

EQUIPMENT that can inadvertently become CONTAMINATED, despite best efforts, must be inspected and removed or DECONTAMINATED to reduce the potential for infection. OSHA regulations regarding CONTAMINATION of EQUIPMENT state that any “equipment which may become contaminated with blood or other potentially infectious materials” shall be examined and DECONTAMINATED as necessary (Bloodborne Pathogens, 2012). Any items or instruments that are no longer necessary to the procedure should be removed promptly. There is potential for CONTAMINATION of EQUIPMENT if used and clean INSTRUMENTS come into contact with one another (Griffith and Tengnah, 2005). 2.9 OSHA regulations regarding eating or drinking in BODY ART PROCEDURE AREAS are as follows: 1910.1030(d)(2)(ix) Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. 1910.1030(d)(2)(x) Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or other potentially infectious materials are present. (Bloodborne Pathogens, 2012). Exceptions can be made when it is necessary to render first aid, such as when a CLIENT is feeling faint. In such instances, BODY ARTISTS must make their best effort to avoid cross-contamination by following basic protocols such as properly removing GLOVES and washing their hands prior to providing the CLIENT with water. Additionally, the BODY ART ESTABLISHMENT should make available closed water bottles kept outside of PROCEDURE AREAS. 2.10 BODY ARTISTS can obtain a COMPLAINT OF INJURY FORM from their DEPARTMENT. Should their DEPARTMENT not have a COMPLAINT OF INJURY FORM, the BODY ART ESTABLISHMENT will need to create one. As stated in this Code, one of the circumstances that requires BODY ARTISTS to submit a COMPLAINT OF INJURY FORM is any communicable disease resulting from the BODY ART PROCEDURE. Diseases that are considered communicable vary by state and PERSONNEL should remain aware of their jurisdiction’s regulations and communicable disease list or reach out to their DEPARTMENT for further guidance. 2.11 The BODY ARTIST shall report all adverse events relating to or suspected of being related to materials used during a BODY ART PROCEDURE to the DEPARTMENT and MedWatch, FDA’s medical product safety reporting program. MedWatch receives reports from the public and publishes safety alerts for FDA-regulated products when appropriate (FDA, 2021b). The utilization of this system streamlines reporting practices and allows adverse reactions to be tracked and potential common causes of such reactions to be found and dealt with appropriately.

3. Jewelry Standards

3.1 All JEWELRY used for initial piercings must meet the following standards: 1. The first piece of JEWELRY that a BODY ARTIST inserts into a piercing, referred to as initial JEWELRY, is worn inside an open wound. As it is in contact with a CLIENT’S internal tissues, this initial JEWELRY must be BIOCOMPATIBLE to avoid adverse reactions such as contact dermatitis, scar tissue, infection, and other issues that might arise with the use of substandard JEWELRY. To ensure JEWELRY is BIOCOMPATIBLE, this Code requires the JEWELRY to meet standards based on those set by the International Organization for Standardization (ISO), American Society for Testing and Materials (ASTM), and APP. ISO establishes expert reviewed and approved international standards across industries to “ensure quality and safety in both products and services” (Approachable Certification, 2016). ASTM one of the largest voluntary standards developing organizations in the world, develops standards for materials, products, systems, and services. Materials listed in Section 3 of this Code with ASTM International or ISO standards are BIOMEDICAL materials proven safe for human implant standards (ASTM 2020). Materials listed without ASTM International or ISO standards are chosen based on the research and expertise of APP and other industry experts. 2. Solid 14-karat or higher gold JEWELRY that is nickel and cadmium free is essential for BIOCOMPATIBILITY. Nickel is a common allergen that has been shown to cause skin irritation or allergic reaction in some individuals (ECARF, 2014). Cadmium is not suitable for body piercings as potential health risks are associated with the toxic metal (Pouzar et al., 2017). Even low exposure levels of cadmium can cause accumulation in the human body. 3. Platinum that is nickel-free and cadmium-free is a highly BIOCOMPATIBLE metal that is resistant to corrosion and oxidation and is considered a highly inert metal (APP, 2020; UC Berkeley, 2019). 4. Unalloyed niobium is a highly BIOCOMPATIBLE metal that is resistant to corrosion and oxidation, even in harsh environments or when in contact with bodily fluids (Safavi et al., 2022). 5. All glass JEWELRY must be free of lead. Lead is a toxic heavy metal that can cause serious health problems if it comes into prolonged contact with the skin (CDC, 2023; DTSC, n.d.). According to the CDC (2023), even small amounts of lead exposure over time can accumulate in the body and cause lead poisoning. Lead exposure can cause adverse health effects, including but not limited to nervous system problems, developmental delays, and organ failure (DTSC, n.d.). 6. JEWELRY should not have threads on the exterior of posts and barbells. This can ensure that the JEWELRY passing through the skin is smooth and reduces the possibility of scraping or irritating tissue with sharp threads (APP, 2020).

7. JEWELRY surfaces and ends should have no irregular surfaces that could scrape or irritate healing tissue and prevent proper healing of the PIERCING (APP, 2020).

8. JEWELRY must have a consistent mirror finish to promote healing of a PIERCING. JEWELRY with uneven or porous surfaces could scrape or irritate healing tissue and cause scar tissue to form (APP, 2020).

9. The ASTM F2999 standard outlines the requirements and test methods for specified elements and mechanical hazards in adult jewelry (ASTM, 2019).

10. The ASTM F2923 standard outlines the requirements and test methods for specified elements and mechanical hazards in children’s jewelry (ASTM, 2020). It also includes recommendations for age labeling and warnings. 4. Specific Regulations for Specific Types of Body Art

4.1 Specific regulations for piercing

1. Clarification of other piercing instruments. 1. EAR-PIERCING GUNS; presterilized SINGLE-USE, stud-and-clasp ear-piercing systems; and similar devices are to be held to the same standards as all other BODY PIERCING techniques because they still pierce the skin or mucosa and thus present pathogen exposure and infection risks. As stated by the Association of Professional Piercers, “the health and safety issues concerning body piercing apply equally to the ear and to all parts of the body” (APP, n.d). 2. EAR-PIERCING GUNS use blunt force to drive JEWELRY through the skin. The effect of this blunt force trauma is more similar to a crush injury than a piercing. Because of the damage this can cause to surrounding cartilage, use of EAR-PIERCING GUNS is limited to the earlobe. Complications that can occur when EAR-PIERCING GUNS are used on structural tissues include, but are not limited to, shattered cartilage, excessive scarring, and auricular chondritis. Cartilage infections take longer to heal than lobe tissue infections because the area has less blood flow. For this reason, cartilage infections can be much more severe, in some cases requiring antibiotic therapy and reconstructive surgery (APP, n.d.a). Potential damage from EAR-PIERCING GUNS is not limited to cartilage. Lobe tissue can also become damaged and infected from EAR-PIERCING GUNS and associated processes. For example, EAR-PIERCING GUNS can malfunction and the force of their spring-loaded mechanism might be insufficient to force the blunt JEWELRY through the skin. In such instances, the JEWELRY must be manually removed or forced through the flesh. Both options present the risk of injury and infection, especially in workplaces that do not meet the regulations for BODY ART ESTABLISHMENTS. Thus, it is required that any establishment that uses an EAR-PIERCING GUN meet the hygiene standards and regulations set forth in this Code to reduce the risk of infection, complications, and disease transmission.

3. The use of STERILE GLOVES during the PROCEDURE helps maintain ASEPTIC TECHNIQUE.

4. The EAR-PIERCING GUN itself presents a high risk for BLOODBORNE PATHOGEN exposure. Most EAR-PIERCING GUNS are partially made of plastic and cannot be STERILIZED to the same extent as other piercing INSTRUMENTS. In LICENSED BODY ART ESTABLISHMENTS, reusable INSTRUMENTS are AUTOCLAVED. This process uses heat, steam, and pressure to STERILIZE INSTRUMENTS between use, killing most pathogens (National Environmental Health Association [NEHA], 2018). Since plastic INSTRUMENTS cannot be AUTOCLAVED, the BODY ARTIST must conduct procedures to ensure the EAR-PIERCING GUN is as clean and STERILE as possible. DISINFECTION and STERILIZATION procedures can be found in Section 8 of this Code. The policy statement from NEHA (2018) on EAR-PIERCING GUNS recommends that state, local, tribal, and territorial government agencies classify the use of EAR-PIERCING GUNS as a piercing PROCEDURE and enforce BODY ART regulations on these ESTABLISHMENTS, as governed by state and local health jurisdictions. The statement also encourages agencies to educate lawmakers and regulators on the public health risk associated with performing piercings with devices that cannot be fully STERILIZED. The full statement discusses this risk as well as the science and justification behind these recommendations and can be found in Appendix A: National Environmental Health Association Policy Statement on Ear Piercing Guns. 4.2 Specific regulations for tattooing/cosmetic tattooing 1. TATTOO inks and pigments can be CONTAMINATED with microorganisms that can cause infection and other serious complications. All inks and pigments must be specifically manufactured for performing BODY ART PROCEDURES. The Food and Drug Administration (FDA) investigates and takes appropriate action when it identifies a safety problem associated with TATTOO ink. However, FDA has traditionally not exercised regulatory authority for color additives on the pigments used in tattoo inks (FDA, 2015). Color additives are subject to premarket approval under the Federal Food, Drug, and Cosmetic Act. However, even with this approval process in place, inks can still be CONTAMINATED. For example, in May 2019, FDA issued a safety advisory regarding six TATTOO inks that were found to be CONTAMINATED with microorganisms and had been voluntarily recalled (FDA, 2019). Inks and pigments for BODY ART PROCEDURES must be manufactured following all current federal regulations. 2. Only distilled water or STERILE WATER may be used for the dilution of inks and pigments. Diluting with potable water is not acceptable. Such dilution must be single use for the individual procedure. Dilution with nonsterile water has been linked to multiple waterborne skin infections caused by Legionella, Pseudomonas, and Mycobacteria (County of San Diego Department of Environmental Health, n.d.). Infections from these bacteria can result in scarring, damage to the TATTOO, severe illness, and when left untreated, can result in fatality. It is essential that BODY ARTISTS use only distilled water or STERILE WATER to ensure CLIENT safety and prevent damaging the BODY ART. In the case of an outbreak or complaint, water should be tested to determine if it is a source of CONTAMINATION.

BODY ARTISTS must also ensure that any prediluted ink is manufactured using STERILE processes and materials. In 2012, FDA reported an outbreak of nontuberculous mycobacterial (NTM) skin infections associated with the use of prediluted gray ink. NTM contamination of inks can occur during the manufacturing process as a result of using contaminated ingredients or poor manufacturing practices, or when inks are diluted with nonsterile water (CDC, 2012). 3. Inks must be placed into SINGLE-USE cups or caps immediately before a TATTOO is applied to minimize potential CONTAMINATION. All SINGLE-USE items must be properly disposed of after the BODY ART PROCEDURE. Requirements for SINGLE-USE items can be found in Section 10 of this Code. SINGLE-USE items and leftover ink that have direct blood contact must be disposed of safely in accordance with Section 11 of this Code. 4. For individuals performing microblading or a manual PROCEDURE, once the needle grouping or blade is attached to the handpiece, it cannot be removed and must be fully disposed of in the SHARPS CONTAINER regardless of whether it has been used. The disposal of manual devices must comply with OSHA’s Bloodborne Pathogens Standard section 1910.1030(d)(2)(vii), which states, “Contaminated needles or other contaminated sharps shall not be bent, recapped, or removed” (OSHA, 2012). In accordance with this interpretation and safety protocols based on scientific evidence, this Code requires that once a needle grouping is affixed to a handle, the needle grouping cannot be removed before disposal in an approved SHARPS CONTAINER. 4.3 Specific regulations for branding 1. The client must be 18 years of age. Parental consent release forms do not apply. Branding is an invasive and permanent PROCEDURE and should not be performed on people under the age of 18. 2. Studies have found human papillomavirus, HIV, infectious poliovirus, and hepatitis B in smoke plumes resulting from laser vaporization, cautery surgery, or similar procedures (Lui et al., 2019). To protect against the harmful smoke generated during a BRANDING PROCEDURE, the PROCEDURE AREA must be completely enclosed. 3. The PROCEDURE AREA must have an appropriately powerful ULTRAVIOLET AIR PURIFIER for the size of the room per the manufacturer’s recommendations. Studies have shown that C-wavelength ultraviolet (UV-C) disinfection is highly effective at inactivating pathogens (Vatansever et al., 2013). According to FDA (2021a), UV-C radiation has been used effectively for decades to reduce the spread of bacteria, including tuberculosis. 4. During the BRANDING PROCEDURE, the BODY ARTIST and CLIENT must wear protective face masks rated as N95 or higher, as the fumes produced when flesh burns can be toxic and spread disease and infection. NIOSH-approved particulate filtering facepiece respirators include N95, Surgical N95, N99, N100, R95, P95, P99, and P100 (NIOSH, 2020).

R esearchers have identified over 600 organic compounds in the smoke generated by burned or vaporized tissue. Many of the identified compounds have documented harmful health effects, including irritation to the eyes, nose, and throat; liver and kidney damage; carcinogenic cell changes, headaches; and dizziness and drowsiness (Ubelacker, 2009). 5. Though there are other types of BRANDING, STRIKE BRANDING and BRANDING using a THERMAL CAUTERY UNIT (TCU) are the only two that can be safely conducted and regulated in a BODY ART ESTABLISHMENT. STRIKE BRANDING is a process by which a BODY ARTIST heats metal and applies it to the CLIENT’S skin. Electrocautery is a process by which a BODY ARTIST uses a TCU, which generates heat via direct or alternating current passing through a resistant metal wire electrode. 6. For STRIKE BRANDING, only nongalvanized metal should be used. Galvanization is the process of applying a zinc coating to metal. Materials containing coated or plated metals can chip or wear off and imbed into the skin, causing metal poisoning and other adverse effects that can require extensive treatment or surgery to remedy (Skin Artists, n.d.). Galvanized metal can produce toxic fumes, the overexposure to which can cause metal fume fever, which is also referred to as zinc chills, zinc shakes, or galvanize poisoning (Langill, 1996). Additionally, galvanized metal does not heat evenly and might only produce second-degree burns, whereas third-degree burns are necessary for safe and effective BRANDING.

7. PROPYLENE GAS must be used for BRANDING PROCEDURES, as it is nontoxic and has superior combustion performance compared to propane gas (Linde, 2021).

4.4 Specific regulations for scarification 1. The client must be 18 years of age. Parental consent release forms do not apply. Scarification is a PROCEDURE that should not be performed on people under the age of 18. 2. SCARIFICATION processes involve cutting into the skin and mucus membranes, which increases the risk of exposure to and infection with BLOODBORNE PATHOGENS, such as hepatitis B, hepatitis C, and HIV. Proper personal protective equipment must be worn to reduce CONTAMINATION risk. BODY ARTISTS must wear disposable sleeves with elastic bands on each end to keep the sleeve in place and to keep out contaminants. 3. SCARIFICATION can create unhealthy airborne toxins. To protect against any harmful airborne byproducts and reduce the spread of airborne pathogens, the SCARIFICATION PROCEDURE AREA must be completely enclosed. 4. The SCARIFICATION PROCEDURE AREA must have an appropriately powerful ULTRAVIOLET AIR PURIFIER for the size of the room per the manufacturer’s instructions. Studies have shown that UV-C disinfection is highly effective at inactivating pathogens (Vatansever et al., 2013). According to FDA (2021a), UV-C radiation has been used effectively for decades to reduce the spread of bacteria, including tuberculosis.

5. The use of STERILE GLOVES during the PROCEDURE helps maintain ASEPTIC TECHNIQUE. The BODY ARTIST must wear STERILE GLOVES when coming into contact with sterile instruments during the PROCEDURE to reduce the risk of CONTAMINATION. 5. Public Notification Requirements 5.1 BODY ART ESTABLISHMENT LICENSES shall be posted in a highly visible location that all CLIENTS have access to, such as the front desk reception/lobby area. 5.2 Individual BODY ARTIST LICENSES shall be posted in a highly visible location, like in a BODY ARTIST station for individual CLIENTS to view. 5.3 AFTERCARE instructions should be provided to CLIENTs in writing, in a manner that does not CONTAMINATE the PROCEDURE AREA. Written AFTERCARE instructions must be posted in a highly visible location that all CLIENTS have access to. The written instructions must contain the name, address, and phone number of the BODY ART ESTABLISHMENT for reporting purposes. 5.4 The BODY ART ESTABLISHMENT shall post the full contact information of the DEPARTMENT that has jurisdiction over the facility and the process for filing a complaint in a highly visible location so that any PERSON who wishes to ask questions or file a complaint has a clear method by which to do so. 5.5 Providing BODY ART requirements of the DEPARTMENT upon request ensures transparent communication with the public and promotes public health and safety. 6. Facility Documentation Requirements 6.1 A BODY ART FACILITY must establish a written plan to address various aspects of infection control and safety measures that ensure the well-being of both personnel and CLIENTS as well as maintaining compliance with regulatory standards. A written plan to eliminate or minimize personnel exposure to blood or other potentially infectious materials (OPIM) can reduce the risk of occupational exposure to bloodborne pathogens. The written plan should detail procedures of proper handling, storage, and disposal of REGULATED WASTE as outlined in Section 11 of this Code. The written plan should include protocols for DISINFECTION AND STERILIZATION of instruments using appropriate methods and validated processes as outlined in Section 8 of this Code. 6.2 Recordkeeping is an essential practice that allows OPERATORS and officials to act swiftly in the name of public health. Records must be made available to the DEPARTMENT upon request, and the DEPARTMENT and BODY ART ESTABLISHMENT must keep records confidential. Only AUTHORIZED AGENTS and PERSONNEL trained in handling confidential records should be granted access. After the minimum time for record retention has passed, all records should be destroyed in a manner that protects the confidentiality of all CLIENT and/or PERSONNEL- related documents.

6.3 A BODY ART ESTABLISHMENT must maintain FACILITY information records to ensure transparency, accountability, and the promotion of public health and safety standards. These records must include current local regulations pertaining to the BODY ART PROCEDURES performed in the FACILITY to ensure both CLIENTS and employees are aware of current applicable regulations. 6.4 Operational Records 1. Operational records, whether in print or electronic, shall be retained in accordance with the DEPARTMENT or at minimum following the 3-year requirement of this Code. 2. Further information about operational records 1. DISINFECTION and STERILIZATION instructions must be available for all EQUIPMENT and surfaces in the BODY ART ESTABLISHMENT. These instructions shall include manufacturer’s instructions and should be in accordance with Section 8 of this Code. Record of instruments purchased pre-sterilized 2. Records of presterilized INSTRUMENTS are necessary to protect public health and ensure traceability and compliance in the event of an outbreak. Records of presterilized items must include the manufacturer’s indication of STERILIZATION. CDC provides a standard minimum retention time for STERILIZATION records of 3 years, which is the time frame requested by the Joint Commission for the Accreditation of Healthcare Facilities (Rutala et al., 2019). 3. Equipment Information 1. BODY ARTISTS must record all materials and STERILIZED INSTRUMENTS used during the PROCEDURE to account for the adherence to STERILIZATION requirements in Section 8 of this Code. This information must be recorded in a STERILIZATION log. 2. EQUIPMENT maintenance records must be maintained according to Section 8 of this Code. 3. A BODY ART ESTABLISHMENT’S procedure for responding to a positive spore test should be included in its Exposure Control Plan. The facility must adhere to the procedure outlined in Section 8.11.1-7 of this Code. 4. REGULATED WASTE is regulated on a state and local level. OPERATORS must determine what their local regulations are and what records they must keep. Recordkeeping is essential for the disposal of REGULATED WASTE to ensure traceability in the event of an exposure incident to blood or OPIM. 5. Red bag letters are necessary to ensure that waste management personnel are informed about the contents of the red biohazard bags they are handling, enabling them to take appropriate precautions. This letter may contain important information regarding the contents of the bag such as the type of waste, any potential hazards, proper handling instructions, and relevant regulatory requirements for disposal.

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