Notice Of Personal Services Setting Form

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Premises Name

Select choices

New Premises
Existing Premises
Addition of Services
Renovation

Premises Site Address

City

Postal Code

Premises Mailing Address

City

Postal Code

Premises Phone Number

Premises Fax Number (if applicable)

Premises email

Premises website (if applicable)

Owner's Name

Is the Operator information the same as the Owner information listed above?

YesNo

If no, list the Operator's Name

Do you rent/lease out any space within the premises listed above to another PSS operator?

YesNo

If yes, please list Name of Personal Services Setting

Open Year-round
Open Seasonally

If seasonal, list months above

Medical Aesthetics

Injectables / Fillers
Microdermabrasion
Laser / Light treatments
Medical facials

Other

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, 1990 and Ontario Regulation 136/1

I Acknowledge