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.
VERIFICATION OF FACILITY
Permit Year: ________________ Reviewed By: ________ Date: _____________
CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD, CA 94520
(925) 692-2500 (925) 692-2502 FAX
www.cchealth.org/eh/
BODY ARTS TEMPORARY
EVENT APPLICATION
APPLICATION FEE IS NON-REFUNDABLE (SERVICE FEES
ARE ADDITIONAL REFER TO FEE SCHEDULE)
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): _______________________________
Signature:___________________________________________________ Date:___________________________
