Fillable Form 2120: Tattooing Piercing Permanent Cosmetics Branding (Contra Costa Health Services)

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Form 2120: Tattooing Piercing Permanent Cosmetics Branding (Contra Costa Health Services)

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  • 15 check-boxes
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File type: PDF

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9/2019 Page 1 of 2
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 TEMPORARY PRACTITIONER APPLICATION
Registration expires 15 days from start of event/class
(Incomplete applications will not be accepted)
Operating at: □ Temporary Event □ Body Arts School □ Permitted Facility
Application for:
□ Tattooing □ Piercing □ Permanent Cosmetics □ Branding
Submit the following (required):
□ Completed Body Arts Temporary Practitioner Application form with signature.
□ 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 $100.00 and $45.00 application fee. Fees are subject to change. Please see the current fee schedule.
A. Practitioner 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: Email address provided must be able to accept email from external email address.
B. Facility or Event Address:
NAME OF EVENT OR SCHOOL:
EVENT COORDINATOR:
PHONE #:
STREET ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
C. Accounts Receivable Address:
IN CARE OF (Billing office or Person in Charge):
BILLING ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
Please complete all pages of this form.
FOR OFFICE USE ONLY
PI #:
AR #:
REHS:
AMOUNT DUE:
$ 145.00
AMOUNT PAID:
RECEIVED BY:
CHECK#:
CASH/CC:
□
MC
□
VISA
□
D/C
SUPERVISOR:
9/2019 Page 2 of 2
FACILITY OR EVENT INFORMATION
LIST ALL ESTABLISHMENTS WHERE YOU ARE PLANNING TO ENGAGE IN TATTOOING, BODY PIERCING, BRANDING
OR PERMANENT COSMETICS. MUST BE A PERMITTED ESTABLISHMENT.
ISSUANCE DATE (START OF
EVENT/CLASS)
END DATE (MAX. 15 DAYS)
DATE(S) PERFORMING ON CLIENTS
THIS REGISTRATION IS TEMPORARY AND WILL EXPIRE WITHIN 15 DAYS OF ISSUANCE.
REGISTRATION MUST BE COMPLETED 5 DAYS BEFORE EVENT/CLASS OR BE SUBJECT TO LATE
FEES. APPROVED REGISTRATIONS WILL BE EMAILED TO THE PRACTITIONER AND EVENT
SPONSOR.
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 Temporary Registration 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:_______________________
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Form 2120: Tattooing Piercing Permanent Cosmetics Branding (Contra Costa Health Services)

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Completed 10 January 2021

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