Fillable Ba Annual Application Packet 9 2019 (City of Long Beach California)

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Ba Annual Application Packet 9 2019 (City of Long Beach California)

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CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Rev. 08/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
BODY ART ANNUAL APPLICATION CHECKLIST
Body Art Practitioner Annual Registration Application
Proof of HEP B Vaccination or Declination Form
Body Art Facility Infection Prevention & Control Plan
Guideline Application
Client Consent Form
After Care Instructions
Blood Borne Pathogen Annual Certificate
Copy of State Identification Card
SUBMIT COMPLETED APPLICATION TO VICTORIA CHAVEZ AT VICTORIA.CHAVEZ@LONGBEACH.GOV
Additional Forms/Resources:
• Blood Borne Pathogen Exposure Control Training Classes
• Sample Exposure Plan for OSHA Standard 1910.1030
• CA Department of Public Health Medical Waste Transporters
ONCE APPROVED, THE APPLICANT WILL BE BILLED FOR PAYMENT
COMPLETION OF THE CHECKLIST DOES NOT GURANTEE COMPLIANCE WITH STATE LAW.
THIS IS SOLELY INTENDED AS A GUIDELINE FOR PROPER GENERAL SET UP
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Rev. 08/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
BODY ART PRACTITIONER ANNUAL REGISTRATION APPLICATION
I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions)
□ Tattooing □ Body Piercing □ Permanent Cosmetics □ Branding
II. APPLICANT INFORMATION:
Name:
___________________________________________ E-mail: _________________________
Mailing Address: ____________________________________County__________________________
City: ____________________ State: ______ Zip: _________ Phone/Cell Phone: __________________
Date of Birth:
__________________________ Gender: □Female □Male
Identification Type:
□Drivers License □Other Identification No.:_____________________
Evidence of Six-months of Related Experience
Facility Name:
____________________________________________________________________
Address:
______________________________ City/County: ____________________ State: _______
Service you Provided: _______________________________________________________________
Supervisor Name and Contact Information: _________________________________________________
Bloodborne Pathogen Training: Submit Certificate
Date Completed:
_____________________ Training Provided by: ______________________________
Hepatitis B Vaccination Status: Choose One and Submit Documentation
1 □ Certification of Completed Vaccination 3 □ Contraindicated for Medical Reasons
2 □ Laboratory Evidence of Immunity 4 □ Vaccination Declination
III. FACILITY LOCATION(S) WHERE YOU PRACTICE: (Attach additional sheets as necessary)
1. BUSINESS NAME:
_______________________________________________________________
Owner/Contact: _____________________________________ Phone: ________________________
Location address: _________________________________________________________________
City: ________________________________ State: ______________________ Zip: ____________
2. BUSINESS NAME: _______________________________________________________________
Owner/Contact: _____________________________________ Phone: ________________________
Location address: _________________________________________________________________
City: ________________________________ State: ______________________ Zip: ____________
The undersigned hereby applies for a Body Art Practitioner Annual Registration and agrees to operate in accordance with all
applicable state and local requirements governing safe body art practices.
I hereby certify that to the best of my knowledge and belief that the statements made herein are true and correct.
Signature:
____________________________________________ Date: ________________________
FOR OFFICE USE ONLY:
Program (PE): ________________ Fees: ____________ Authorized by (REHS): __________ _________
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CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Rev. 08/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
DEFINITIONS AND REFERENCES
I. PROCEDURES TO BE PERFORMED (§ 119300)
TATTOOING – means the insertion of pigment in the human skin by piercing with a needle.
BODY PIERCING – means the creation of an opening in a human body for the purpose of inserting
jewelry or other decoration. “Body piercing” includes, but is not limited to, the piercing of an ear, lip, tongue,
nose, or eyebrow. “Body piercing” does not include the piercing of an ear when using a disposable,
single-use, pre-sterilized clasp and stud or solid needle that is applied using a mechanical devise to force
the needle or stud through the ear (with one exception).
PERMANENT COSMETIC - means the application of pigments in the human skin tissue for the
purpose of permanently changing the color or appearance of the skin. This includes, but is not limited to,
permanent eyeliner, eyebrow, or lip color.
BRANDING – means the process in which a mark or marks are burned into the human skin tissue
with a hot iron or other instrument, with the intention of leaving a permanent scar.
II. APPLICANT INFORMATION (§ 119306, § 119312, § 119325)
All applicants must provide government-issued identification with full name, mailing address, contact
information and date of birth.
All body art practitioners must
submit documentation on:
• Hepatitis B vaccination status
• Proof of blood-borne pathogen training.
First-time registrants must provide evidence of six-months of relate experience, including the contact
information for the facility where they obtained the experience.
III. FACILITY LOCATION (§ 119306, § 119312, § 119325)
All applicants must provide the business name, location address, and contact information in which they
will perform body art. If a practitioner performs at multiple locations, each location must be identified.
RETURN ANNUAL REGISTRATION APPLICATION TO:
City of Long Beach
Department of Health and Human Services
Bureau of Environmental Health
Attn: Victoria Chavez
2525 Grand Avenue, Room 220
Long Beach, CA 90815
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
Voluntary Declination of Hepatitis B Vaccination
I understand that due to my occupational exposure to blood or OPIM (Other Potentially
Infectious Materials) I may be at risk of acquiring the 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 Hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I
continue to have occupational exposure to blood or OPIM and I want to be vaccinated with
Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
________________________________ _____________________________________
Name Date
________________________________ _____________________________________
Signature California Drivers License of Identification #
If a practitioner declines the Hepatitis B vaccination, a copy of this declination must be
submitted with the Body Art Practitioner Registration Form and provided to the operator of
each location where the practitioner performs body art.
NOTE: The owner of the body art facility where the body art practitioner works is responsible for
providing the vaccination series at no cost. The City of Long Beach does not provide this service.
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CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 1 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
BODY ART FACILITY INFECTION PREVENTION AND CONTROL PLAN GUIDELINE
APPLICATION
In accordance with the California Health and Safety Code, Section 119313, a body art facility
shall maintain and follow a written Infection Prevention and Control Plan, provided by the
owner or established by the practitioners, specifying procedures to achieve compliance with
the Safe Body Art Act. A copy of the Infection Prevention and Control Plan shall be filed with
the Local Enforcement Agency and a copy maintained in the body art facility.
The body art facility owner shall provide onsite training on the facility’s Infection Prevention
and Control Plan to the body art practitioners and employees or individuals involved with
decontamination and sterilization procedures.
Training shall be provided when tasks where occupational exposures may occur are initially
assigned, anytime there are changes in the procedures or tasks and when new technology is
adopted for use in the body art facility, but not less than once each year. Records of training
shall be maintained on-site for three years.
Name of Body Art Facility:
Site Address:
City, State, Zip:
Type of Body Art Facility:
Contact Person: Telephone:
A. Decontamination and Disinfection: Describe the procedures for decontaminating and
disinfecting of workstation and surfaces.
1. Workstation surfaces/counter tops:
2. Workstation chairs/stools:
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 2 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
3. Trays:
4. Armrests:
5. Headrests:
6. Procedure area:
7. Tables:
8. Tattoo machine:
9. Reusable instruments, calipers, needle tubes, etc., or other:
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 3 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
B. Reusable Instruments: Describe the procedures used for decontaminating, sterilizing,
packaging and storing of reusable instruments. Include the procedures for labeling of
sterilized peel-packs.
1. Needle tubes:
2. Calipers:
3. Other instruments:
C. Storage: Describe the storage location and equipment used for the storage of clean and
sterilized instrument peel packs to protect the packages from exposure to dust and moisture.
D. Set Up and Tear Down of Workstation: Describe the procedure for setting up and tearing
down the workstation for the following procedures.
1. Tattoo:
2. Piercing:
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 4 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
3. Permanent Cosmetics:
4. Branding:
E. Prevention of Cross Contamination: Describe the techniques used to prevent the
Contamination of instruments, tattoo machine, trays, tables, chairs, clip cords, power
supplies, squeeze bottles, inks, pigments, lamps, stools, soaps and the procedure site or
other items during a body art procedure. Include barriers provided to prevent cross
contamination. Describe how the procedure site is prepared for a body art procedure.
F. Sharps containers: Describe the procedures for the safe handling of sharps and indicate the
location of the sharps containers.
G. Sharps Disposal: Describe the disposal of sharps used during a body art procedure.
1. Needles and needle bars:
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 5 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
2. Razors:
3. Other sharps or single-use marking pens:
H. List the Medical Waste Hauler, Mail-Back System or Alternative Treatment Technology
for the disposal of sharps containers:
Medical Waste Hauler
Street Address
City, ST, Zip
I. Sterilization of Jewelry: Describe the procedure for the sterilization of jewelry prior to placing
into newly pierced skin.
J. Sterilization Equipment: List the equipment used in the decontamination and sterilization
room and describe the procedure for decontaminating instruments prior to placing inside the
autoclave. Indicate whether instruments are manually washed or machine washed, such as
with an Ultrasonic machine. Include the material used for soaking dirty instruments in the
machine, such as Tergazyme.
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 6 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
K. Disinfection Products: List the disinfectant products used at the body art facility.
L. Time and Temperature: List the duration of time and temperature of the autoclave required
For the sterilization of clean instruments.
Time __________
Temperature __________
Psi __________
M. Personal Protective Equipment: List the personal protective equipment used during a body
art procedure.
N. Handwashing Sink: List the locations of the handwash sinks and describe the items supplied
at each sink.
O. Aftercare Procedure: Describe the written recommendations and care provided to the client
after a body art procedure. List the type of bandages or wrappings provided after a body art
procedure.
P. Procedure for an Accidental Spill: Describe the clean-up and disinfection procedure taken
when there is an accidental spill of sharps or biohazardous waste.
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 7 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
Q. Trash Receptacles and disposal of contaminated trash: List the type of trash receptacles
and their location throughout the body art facility. Describe the procedure for the disposal of
contaminated items, such as gloves.
R. Negative/Failed Spore Test: Describe the procedure conducted when a monthly spore test
has failed.
Maintain a copy of this document in your files. Submit one copy to the Local Enforcement
Agency.
I hereby certify that to the best of my knowledge and belief, the statements made herein are
correct and true.
Signature: __________________________________________ Date: _________________
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 8 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
STERILIZATION PROCEDURES
When a body art facility is equipped with a decontamination and sterilization room and will be
sterilizing reusable instruments and body art jewelry, the following sterilization procedures must
be followed:
1. Clean instruments to be sterilized shall first be sealed in peel-packs that contain either a
sterilizer indicator or internal temperature indicator. The outside of the pack shall be labeled
with the name of the instrument, the date sterilized, and the initials of the person operating the
sterilizing equipment.
2. Sterilizers shall be loaded, operated, decontaminated and maintained according to
manufacturer’s directions, and shall meet all of the following standards:
• Only equipment manufactured for the sterilization of medical instruments shall be used.
• Sterilization equipment shall be tested using a commercial biological indicator monitoring
system after the initial installation, after any major repair, and at least once per month.
The expiration date of the monitor shall be checked prior to each use.
• Each sterilization load shall be monitored with mechanical indicators for time,
temperature, pressure, and, at a minimum, Class V integrators. The Class V integrator
gives an immediate response on whether the sterilization has been achieved. Each
individual sterilization pack shall have an indicator.
• Biological indicator monitoring test results shall be recorded in a log that shall be kept on
site for two years after the date of the results.
• A written log of each sterilization cycle shall be retained on site for two years and shall
include all of the following information:
(a) The date of the load.
(b) A list of the contents of the load.
(c) The exposure time and temperature.
(d) The results of the Class V integrator.
(e) For cycles where the results of the biological indicator monitoring test are positive,
how the items were cleaned, and proof of a negative test before reuse.
3. Clean instruments and sterilized instrument packs shall be placed in clean, dry, labeled
containers, or stored in a labeled cabinet that is protected from dust and moisture. Use clean
gloves to handle sterilized packages to prevent cross contamination of the sterilized item
when the package is opened for use.
4. Sterilized instruments shall be stored in the intact peel-packs or in the sterilization equipment
cartridge until time of use.
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 9 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
5. Sterile instrument packs shall be evaluated at the time of storage and before use. If the
integrity of a pack is compromised, including, but not limited to, cases where the pack is torn,
punctured, wet, or displaying any evidence of moisture contamination, the pack shall be
discarded or reprocessed before use.
6. A body art facility that does not afford access to a decontamination and sterilization area that
meets the standards of subdivision (c) of Section 119314 of the California Health and Safety
Code or that does not have sterilization equipment shall use only purchased disposable,
single-use, pre-sterilized instruments. In place of the requirements for maintaining
sterilization records, the following records shall be kept and maintained for a minimum of 90
days following the use of the instruments at the site of practice for the purpose of verifying the
use of disposable, single-use, pre-sterilized instruments:
• A record of purchase and use of all single-use instruments.
• A log of all procedures, including the names of the practitioner and client and the date of
the procedure.
OPERATING CONDITIONS FOR AUTOCLAVE
Cleaning: Remove all material on the instruments during the cleaning process to ensure that the
sterilization process is achieved. The cleaning process can be a manual cleaning or by use of an
ultrasonic machine.
Packaging: Package the instruments with hinges in the open position to ensure that the ridges
and crevices of the instruments are sterilized.
Loading: Load the autoclave with the packages upright on their sides. Peel packs should be on
edge with the plastic side next to a paper side to allow for steam penetration. Do not overload
the autoclave to allow proper flow of the steam to achieve sterilization.
Steam Sterilization: Temperature should be 121°C or 250° F; pressure should be 106kPa
(15lbs/in2); 30 minutes for packaged items. At a higher temperature of 132° C or 279° F,
pressure should be 30 lbs/in2; 15 minutes for packaged items.
Allow all items to dry before removing them from the autoclave. Use clean gloves to handle
packaged items.
Pressure settings (kPa or lbs/in2) may vary slightly depending on the autoclave used. Follow
manufacturer’s recommendations for your autoclave.
Exposure time begins only after the autoclave has reached the target temperature.
Source: Adopted from Principles and Methods of Sterilization in Health Sciences. JJ Perkins. 1983
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES | BUREAU OF ENVIRONMENTAL HEALTH
BODY ART PROGRAM
Page 10 of 10 Rev 7/2019
2525 Grand Avenue, Room 220 | Long Beach, CA 90815 | Phone: (562) 570-4132 Fax: (562) 570-4038
www.longbeach.gov/health/eh
STERILIZATION LOG
Date Load Contents Operator Time Temp PSI
Temp
Indicator
Results
Attach
Integrator Here
Spore Test
Results
Action Taken Due to Failed
Result
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Ba Annual Application Packet 9 2019 (City of Long Beach California)

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Completed 14 July 2020

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