Fillable BODY ART PRACTITIONER PACKET (County of San Bernardino Information Services Dept.)

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BODY ART PRACTITIONER PACKET (County of San Bernardino Information Services Dept.)

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12/2019
Body Art Practitioner Packet
Page 1 of 3
385 N. Arrowhead Ave., 2nd floor, San Bernardino, CA 92415
Email: EHS.CustomerService@dph.sbcounty.gov
Website: wp.sbcounty.gov/dph/ehs
Text/Call: 800.442.2283
Fax: 909.387.4323
BODY ART PRACTITIONER PACKET
Complete Application for Body Art Practitioner Registration, (see page three)
Meet Hepatitis B requirements in one of the following ways:
A. Provide evidence of current Hepatitis B vaccination (including boosters) OR
B. Comply with current Federal Occupational Safety and Health Administration (OSHA) Hepatitis B
vaccination declination requirement OR
C. Demonstrate Hepatitis B immunity
Provide evidence of completion of OSHA Bloodborne Pathogen Training (trainers must be approved by
the County of San Bernardino)
Provide valid photo identification (must be at least 18 years of age) for first-time registrants
Provide signature on the Application for Body Art Practitioner Registration verifying self-certification of,
knowledge of, and commitment to meet state law and relevant local regulations pertaining to body art
safety. Regulations for the California Safe Body Art Act can be accessed through the Environmental
Health Services (EHS) website
Pay applicable body art registration fee
A valid and current registration issued by EHS will be valid in any other jurisdiction for no more than
five consecutive days, or 15 days total, in any one calendar year.
A practitioner may, in the local jurisdiction of registration, practice in a temporary demonstration booth
for no more than seven days in a 90-day period.
A practitioner shall display a certificate confirming registration with the local enforcement agency.
The Body Art Practitioner Registration shall be visible to the public at the body art facility where the
practitioner is performing body art.
A body art practitioner must:
Maintain a valid practitioner registration
Use proper hygiene before performing body art
Answer questions regarding the procedure site
Provide post-procedure instructions
Properly discard sharps waste
Properly clean, sanitize, and protect instruments and equipment
Maintain a clean and sanitary environment
Comply with all applicable laws and regulations regarding safe body art
Practitioner registration inspections (including charged inspections) may be conducted for the following
actions:
Practicing with expired registration or without current bloodborne pathogens exposure control training
Using unsafe practices on client(s)
Repeat violations
A body art practitioner practicing body art in violation of the Safe Body Art Act resulting in an imminent
health hazard may have his/her registration suspended or revoked. The registrant has the right to request
(in writing) a hearing to show cause why his/her registration should not be suspended or revoked. A
failure to request a hearing within 15 calendar days after receipt of the notice will be deemed a waiver of
the right to a hearing.
__
__
__
Notify EHS when switching facilities or when no longer practicing body art
12/2019 Body Art Practioner Packet- HBV
Page 2 of 3
385 N. Arrowhead Ave., 2nd floor, San Bernardino, CA 92415
Email: EHS.CustomerService@dph.sbcounty.gov
Website: wp.sbcounty.gov/dph/ehs
Text/Call: 800.442.2283
Fax: 909.387.4323
HEPATITIS B VIRUS IMMUNITY REQUIREMENTS
In accordance with Occupational Safety and Health Administration (OSHA) requirements, employers must
make Hepatitis B vaccinations available at no cost to employees who have an occupational exposure to the
Hepatitis B virus (HBV). Body art practitioners are required to submit evidence of current HBV immunity in
conjunction with registration materials. This includes records of Hepatitis B vaccinations and booster shots.
If a practitioner declines vaccination against HBV, he/she must submit a signed declination agreement from
his/her employer. See below for declination statement.
Contact Occupational Safety & Health Administration (www.osha.gov) for additional information.
HEPATITIS B VACCINE DECLINATION
EMPLOYER INFORMATION
Facility Name:
Facility Address:
Facility Phone Number:
Hepatitis B Vaccine Declination for:
(Applicant’s full name)
“I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at
risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with
Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I
understand that by declining this vaccine, I continue to be at risk of acquiring HBV. If in the future I continue to
have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with
the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.”
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61
FR 5507, Feb. 13, 1996]
Applicant’s Signature: Date:
Facility Owner’s Name:
Facility Owner’s Signature: Date:
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12/2019 Application Body Art Practitioner Registration
385 N. Arrowhead Ave., 2nd floor, San Bernardino, CA 92415
Email: EHS.CustomerService@dph.sbcounty.gov
Website: wp.sbcounty.gov/dph/ehs
Text/Call: 800.442.2283
Fax: 909.387.4323
APPLICATION FOR BODY ART PRACTITIONER REGISTRATION
THIS SECTION TO BE COMPLETED BY APPLICANT
APPLICANT INFORMATION
Full Name:
Date of Birth:
Date:
Home Address:
State:
Zip:
Work Address:
State:
Zip:
Mailing Address
(if different from above)
:
City:
State:
Zip:
Phone Number:
Email:
First time registering? Yes No Practitioner Registration Number (PRXXXXXXX):
PERMITTED FACILITY INFORMATION
Business Name:
Business Address (where applicant will be performing activities):
City:
State:
Zip:
Type of Activities: Tattoo Body Piercing Permanent Cosmetic Branding Body Art Training
All of the following must be provided with the application:
Evidence of current Hepatitis B vaccination (including boosters)
OR
Evidence that applicant has complied with current Federal Occupational Safety and Health Administration (OSHA)
OR
Applicant is able to demonstrate Hepatitis B immunity
Evidence of completion of OSHA Bloodborne pathogen training (consistent with Section 119307 of the California
Code of Regulations). An approved list of trainers can be found on wp.sbcounty.gov/dph/programs/ehs/body-art/.
Annual registration fee (Make checks payable to: County of San Bernardino)
Valid photo identification (for new applicants only)
DECLARATION AND SIGNATURE
I declare under the penalty of law, that to the best of my knowledge and belief, the statements made herein are correct
and true. I certify that I am at least 18 years of age. I have knowledge of, and commit to meet state law and relevant
local regulations pertaining to body art safety. I hereby submit this application for health services in accordance with the
laws, ordinances and regulations that are now and may herein after be in force by the Federal Government, State of
California, and San Bernardino County pertaining to Body Art Practitioners. I hereby consent to all necessary
inspections incident to the issuance of this registration. Furthermore, I understand that failure to meet all requirements of
the Safe Body Art Act and San Bernardino County may result in legal action including, but
not limited to, a
dditional
charged inspections, suspension or revocation of my registration.
By checking this box, I confirm I am submitting this application electronically and that the information on this form is
true and correct. I also acknowledge that I have read, understand and accept any terms and conditions of this form.
Signature:
Date:
Print Name:
Title:
OFFICE USE ONLY
Fee:
FA Number:
Record ID:
PE Number:
Late Fee: Y N
Designated Employee:
Received By:
Date:
Check One: New Renewal Reactivate
Changes (specify):
P
age 3 of 3
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Completed 24 February 2021

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