| Name of Facility |
| Address |
| Owner/Operator Number of Operators |
| Number of chairs Number of Tables |
| Operators Names: |
| 1 3 |
| 2 4 |
| | REMARKS |
| I | FLOORS | |
| 1 | (a) Easily cleanable construction, smooth, good repair | |
| 1 | (b) Clean | |
| 1 | (c) Receptacles covered | |
| 3 | Separate label receptacles for sharps and biomedical waste | |
| II | WALLS AND CEILINGS | |
| 1 | All clean light coloured | |
| 1 | Good repair | |
| III | VENTILATION AND LIGHTING | |
| 1 | (a) Well lighted 100-foot candles | |
| 1 | (b) Well ventilated | |
| 1 | (c) Free from odors and condensation | |
| | REMARKS |
| IV | CHAIRS AND EQUIPMENT | |
| 2 | (a) Easily cleaned and disinfected | |
| 1 | (b) No open seams or tears | |
| 1 | (c) Cases, shelves, tables, mirrors etc. clean and free of dust and powder | |
| 1 | (d) In good repair | |
| V | LAVATORY (SINKS) FACILITIES | |
| 1 | (a) Adequate in number and convenient for use | |
| 1 | (b) Clean | |
| 1 | (c) Soap or detergent, hand-drying device provided at each station | |
| 1 | (d) Free of soiled linen | |
| VI | WATER SUPPLY | |
| 2 | (a) Adequate supply of both portable hot and cold running water | |
| VII | TOILET FACILITIES | |
| 1 | Number, convenient, accessible, designed | |
| 2 | Enclosed, self-closing doors, fixtures in good repair, clean, hand drying devices and waste receptacle provided | |
| 2 | Ventilation adequate | |
| 2 | Separate washrooms for both sexes | |
| VIII | LINEN | |
| 1 | (a) Adequate supply of clean linen/ disposable table sheets | |
| 1 | (b) Clean linen stored in closed cabinet | |
| 1 | (c) Towels or washcloths used only on one patron | |
| 1 | (d) Soiled linen stored in covered containers | |
| | REMARKS |
| VIII | LINEN | |
| 1 | (e) Protection placed around neck to prevent haircloth from contacting patron's skin | |
| 1 | (f) All linen free from holes, tears and stains | |
| 2 | (g) Separate sterile compartment for the storage of cotton, gauzes etc. | |
| IX | SHOP SANITATION | |
| 2 | Facility in residence or business separated by a partition from floor to ceiling | |
| 1 | No food served or consumed in shop | |
| 4 | Waste container kept clean and sanitary | |
| X | PERSONAL APPEARANCE AND CLEANLINESS | |
| 2 | Neat and clean | |
| 2 | Valid certificate of health | |
| 2 | Clean outer garments and used only for work | |
| 2 | Hands and fingernails clean | |
| XI | HEADREST | |
| 2 | (a) Properly stored when not in use | |
| 2 | (b) Protected with fresh clean paper | |
| XII | TOOLS AND EQUIPMENT | |
| 5 | (a) All tools and equipment free of bodily fluids | |
| 3 | (b) Adequate supply to ensure proper sterilization (minimum of two sets) | |
| 2 | (c) Adequate supply of personal protective equipment (PPE) | |
| XIII | STERILIZATION | |
| 5 | (a) All tools and instruments are sterilized before reuse on another patron | |
| | REMARKS |
| XIII | STERILIZATION | |
| 5 | (b) Sterilization cabinets and wet sterilizers contain adequate fresh disinfectant | |
| 5 | (c) Tools kept in sterilizers at all times when not in use | |
| 2 | (d) Tools not kept in pocket of uniform | |
| 3 | (e) Sterilizing cabinet airtight and free from letters, papers, and articles and to be sterilized | |
| 5 | (f) Adequate equipment and supplies for sterilization | |
| XIV | LICENCE | |
| 5 | (a) Valid licence to operate | |
| 1 | (b) Posted in a conspicuous location to view | |