Fillable Form 2120: BODY ARTS PRACTITIONER APPLICATION (Contra Costa Health Services)

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Form 2120: BODY ARTS PRACTITIONER APPLICATION (Contra Costa Health Services)

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The Form 2120: BODY ARTS PRACTITIONER APPLICATION (Contra Costa Health Services) form is 3 pages long and contains:

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  • 16 check-boxes
  • 53 other fields

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File type: PDF

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Rev. 9/2019 Page 1 of 3
CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120
DIAMOND BOULEVARD, SUITE 100
CONCORD,
CA 94520
(925)
608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
BODY ARTS PRACTITIONER APPLICATION
(Incomplete applications will not be accepted)
NEW Application for: □ Tattooing □ Piercing □ Permanent Cosmetics □ Branding
RENEWAL for: □ Tattooing □ Piercing □ Permanent Cosmetics □ Branding
Submit the following (required):
□ Completed Body Arts Practitioner Application form with signature and Location of Operation Agreement.
□ A copy of your current Contra Costa EH Approved Bloodborne Pathogen
Certificate of Training.
□ Proof of Hepatitis B vaccination or a Hepatitis B declination form.
□ Proof practitioner is over age 18 – copy of photo ID.
□ Registration fee of $150.00. Fees are subject to change. Please see the current fee schedule
.
□ $45.00 non-refundable application fee required for new applicants.
A. Practitioner Physical Address:
PRACTITIONER NAME (As it appears on Driver’s License or Federal Tax ID):
PRACTITIONER HOME ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
EMAIL ADDRESS: Required for Recall notices, Renewal Applications, and Newsletters regarding changes in state law. Email address provided must be able to accept
email from external email address.
B. Accounts Receivable Address: Annual renewal packets to be mailed here
IN CARE OF (Billing office or Person in Charge):
BILLING ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
C. Facility Name Information:
LIST ALL ESTABLISHMENTS WHERE YOU CURRENTLY OR ARE PLANNING TO ENGAGE IN TATTOOING, BODY PIERCING, BRANDING OR
PERMANENT COSMETICS. MUST BE A PERMITTED ESTABLISHMENT.
FACILITY NAME:
ADDRESS:
CITY, ZIP CODE:
PHONE:
FACILITY NAME:
ADDRESS:
CITY, ZIP CODE:
PHONE:
FACILITY NAME:
ADDRESS:
CITY, ZIP CODE:
PHONE:
Please complete all pages of this form.
FOR OFFICE USE ONLY
AR #:
PR #:
REHS:
$
AMOUNT PAID:
RECEIPT #:
RECEIVED BY:
CASH/CREDIT CARD: □MC □VISA
DATE RECEIVED:
SUPERVISOR:
Rev. 9/2019 Page 2 of 3
Section 119306(a) of the California Safe Body Art Act states that a person shall not perform body art at any
locations other than a permitted permanent or temporary body art facility.
THIS LETTER MUST BE RENEWED ANNUALLY BY THE BODY ART PRACTITIONER
FOR EACH FACILITY THEY ARE OPERATING FROM.
CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120
DIAMOND BOULEVARD, SUITE 100
CONCORD,
CA 94520
(925)
608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
PRACTITIONER LOCATION OF OPERATION AGREEMENT
I) THIS SECTION TO BE COMPLETED BY THE BODY ART PRACTITIONER
Practitioner Name:________________________________________ Registration Number:__________________
Practitioner Mailing Address:_________________________________ City:_______________ Zip Code:________
Phone: _____________________________ Email:___________________________________________________
II) THIS SECTION TO BE COMPLETED BY THE BODY ART FACILITY OWNER
The above Body Art Practitioner has my permission to use my permitted Body Art Facility (Listed below) to perform
Body Art. I will notify Contra Costa Environmental Health if the above Body Art Practitioner is no longer practicing
body art at my permitted facility.
Facility Name:_____________________________________________ Health Permit PR #:__________________
Facility Address:________________________________________ City:_______________ Zip Code:___________
Phone: _____________________________ Email:___________________________________________________
Permit Owner Name (Print): _______________________________
Permit Owner Signature:_____________________________________________ Date:___________________________
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Rev. 9/2019 Page 3 of 3
The undersigned hereby certifies all of the information provided on this application is true and accurate and agrees to
notify Contra Costa Environmental Health of any changes that occur including the type of business activity, name,
business location, billing address, and/or cease practicing body art.
The undersigned hereby applies for a Registration Permit and agrees to operate in accordance with all applicable
state and local regulations, laws, and such inspection procedures needed to ensure compliance. Payment of the
required registration fee and outstanding inspection fee balance, if any, to secure a valid registration is required
before commencing or continuing operations. Failure to do so may result in a misdemeanor citation, infractions,
registration suspension/revocation proceedings, and/or closure.
REGISTRATIONS ARE NOT TRANSFERABLE
Signature must be by the Practitioner
. A manually signed copy of this application delivered by facsimile, email or
other electronic transmission shall be deemed to have the same legal effect as delivery of an original signed copy of
this application.
APPLICANT NAME (please print):_______________________________________________________________
Signature of Applicant:_____________________________________________ Date:_______________________
A $45.00 PROCESSING FEE WILL BE CHARGED FOR REPLACEMENT PRACTITIONER CERTIFICATES.
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Form 2120: BODY ARTS PRACTITIONER APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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