Fillable Form 2120: New Facility Change of Ownership (Contra Costa Health Services)

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Form 2120: New Facility Change of Ownership (Contra Costa Health Services)

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The Form 2120: New Facility Change of Ownership (Contra Costa Health Services) form is 2 pages long and contains:

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  • 13 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

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Page 1 of 2
Rev. 9/2019
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 FACILITY APPLICATION
(Incomplete applications will not be accepted)
Description of Work: □ Tattooing □ Piercing □ Permanent Cosmetics □ Branding □ Body Art School
Application Type:
□ New Facility □ Change of Ownership
Submit the following information (required):
□ Completed body arts establishment permit application form with signature.
□ The permit fee for a body arts facility is $796 per year and a body art school is $1,194.00. Fees are subject to change;
please see the current fee schedule
.
□ A copy of the Infection Prevention Control Plan is required to be filed with this application (Section 119312 (b) (1).
□ A consent, medical history, and aftercare form.
Note: Prior to obtaining a permit, any new facility or change of ownership with new procedures must complete the plan review process.
Please see the body arts plan review guide and body arts plan review application for more details.
A. Facility Address:
FACILITY NAME/DBA:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
PREVIOUS FACILITY NAME/DBA:
EMAIL ADDRESS:
For Official Inspection Reports and Newsletters regarding changes in state law. Email provided must be able to accept email from external email address.
B. Owner Physical Address:
NEW OWNER NAME (As it appears on Driver’s License or Federal Tax ID):
OWNER ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
C. Accounts Receivable Address: Invoices to be mailed here.
IN CARE OF (Billing office or Person in Charge):
ACCOUNTS RECEIVEABLE ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
Please complete both sides of this form.
FOR OFFICE USE ONLY
SR:
FA:
PR:
AR:
PROGRAM ELEMENT:
49
64
REHS:
AMOUNT DUE:
$
AMOUNT PAID:
RECEIPT #:
RECEIVED BY:
CHECK#:
CASH CREDITCARD:
□
MC
□
VISA
DATE RECEIVED:
SUPERVISOR:
Page 2 of 2
Rev. 9/2019
LIST OF CURRENT OR FUTURE REGISTERED PRACTITIONERS – State law requires that each practitioner be
registered with the local health department. No body art facility shall allow a practitioner who does not possess a valid
practitioner registration to perform body art procedures at the facility.
Name
Registration Number
Name
Registration Number
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, practitioners, ownership and/or closure.
The undersigned further agrees and understands that any structural alterations, including, but not limited to, equipment
changes or additions requires submittal of plans and appropriate fee to Contra Costa Environmental Health for review and
approval.
The undersigned hereby applies for a Permit to Operate 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 permit fee
and outstanding inspection fee balance, if any, to secure a valid permit is required before commencing or continuing
operations. Failure to do so may result in a misdemeanor citation, infractions, permit suspension/revocation proceedings,
and/or closure.
PERMITS ARE NOT TRANSFERABLE
Signature(s) must be an Owner, Partner or Corporate Officer (Corporation and Limited Liability Companies). 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:_______________________
NONREFUNDABLE DEPOSIT AMOUNT MAY NOT COVER THE ENTIRE APPLICATION REVIEW TIME.
ADDITIONAL HOURS MAY BE BILLED AT THE CURRENT HOURLY RATE.
CONSTRUCTION/REMODEL IS NOT TO COMMENCE UNTIL PLANS ARE APPROVED AND BUILDING PERMITS OBTAINED.
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Form 2120: New Facility Change of Ownership (Contra Costa Health Services)

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Completed 10 January 2021

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