Fillable Form 2120: New Facility Remodel (Contra Costa Health Services)

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Form 2120: New Facility Remodel (Contra Costa Health Services)

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  • 18 check-boxes
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File type: PDF

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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 PLAN REVIEW APPLICATION
Description of Work: □ Tattooing □ Piercing □ Permanent Cosmetics □ Branding □ Body Art School
Plan Review Type:
□ New Facility □ Remodel
A. Facility Address
FACILITY NAME/DBA:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
EMAIL:
PREVIOUS FACILITY NAME/DBA:
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 #:
EMAIL:
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:
FAX #:
PHONE #:
EMAIL:
Please complete both sides of this form.
FOR OFFICE USE ONLY
SR #:
AR #:
PROGRAM ELEMENT #:
49
DISTRICT:
64
REHS:
AMOUNT DUE:
$
AMOUNT PAID:
RECEIPT #:
RECEIVED BY:
METHOD OF PAYMENT: CHECK#:______________
CASH/CREDITCARD: □MC □VISA □D/C
DATE RECEIVED:
SUPERVISOR:
Submit the following information (required):
□ Completed Body Art Facility Plan Review Application form with signature.
□ Plans: For electronic plans use a Portable Document Format (PDF) and have a scaled size of 11 x 17 inches. Email to
body.art@cchealth.org
.
For paper plans, submit 4 copies, minimum paper size is 11 x 17 inches (scaled drawing ¼“ = 1’), with facility name
and address on each page.
□ A copy of your Body Art Facility Infection Prevention and Control Plan.
□ Application for Body Arts Facility Application and a Body Arts Practitioner Application.
□ $796 Plan Review Fee. Please be aware this fee in non-refundable.
□ $398 Remodeling fee. Please be aware this fee is non-refundable.
□ Completed Finish Schedule with equipment/tool spec sheets. Finish schedule be found at: www.cchealth.org/eh/
□ A Consent, Medical History, and Aftercare form. (Not required if remodeling only.)
The body art facility health permit will be issued after plan approval, passing facility inspection, and payment of all
fees.
Rev. 9/2019
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 un
derstands 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 Per
mit 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. (California Health and Safety Code, Division 104, Part 15, Ch. 7 Sections: 119320,
119323)
PERMITS ARE NOT TRANSFERABLE
Signature(s) must be an Owner, Partner or Corporate O
fficer (Corporation and Limited Liability Companies). A
manually signed copy of this applica
tion 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 PLAN 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 Remodel (Contra Costa Health Services)

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Completed 10 January 2021

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