HomeMy WebLinkAboutbodyart-temp-demo-boothpermit-app-and-reg-practitioner-notificationBODY ART TEMPORARY DEMONSTRATION BOOTH PERMIT APPLICATION
AND REGISTERED PRACTITIONER NOTIFICATION
TYPE OF SERVICE: TYPE OF PERMIT:
TATTOO BODY PIERCING PERMANENT COSMETICS BRANDING DEMONSTRATION BOOTH | SEE FEE SCHEDULE
MAKE CHECKS PAYABLE TO ALAMEDA COUNTY
EVENT INFORMATION
NAME OF EVENT: DATES:
EVENT BUSINESS NAME: NAME OF EVENT ORGANIZER:
BOOTH BUSINESS NAME: BOOTH #: # OF PRACTITIONERS:
BILLING ADDRESS: CITY: STATE: ZIP CODE:
CONTACT NAME: PHONE: EMAIL:
Provide names of all body art practitioners at booth, county where registered and registration number for each individual. If practitioner does not have a
California registration, he/she must apply for registration from Alameda County DEH prior to participating in the temporary event. Registration must be
present and visually displayed at the booth along with a photo ID.
NAME COUNTY REGISTERED REGISTRATION #
INSTRUMENT
TYPE OF INSTRUMENT(S): SINGLE-USE DISPOSABLE MULTI-USE EQUIPMENT REQUIRING STERILIZATION
All contaminated equipment must be decontaminated/sterilized prior to being removed from premises
CLIENT FORMS
Informed Consent Forms, Medical History, Aftercare Instructions, Client Procedure Log, Disposable Instrument/Needle Use Log, and
Sterilization Log shall be provided by: EVENT SPONSOR BODY ART OPERATOR
BODY ART DEMONSTRATION BOOTH OWNER/OPERATOR ACKNOWLEDGEMENT
• I have completed the application/notification to the best of my ability.
• I understand that I may be asked to provide additional information in order for the application/notification to be approved and that the information provided
is considered part of the temporary body art event application.
• I understand that each practitioner within this demonstration booth shall have at least 50 sq. ft. of floor space to set up his/her workstation to provide body
art procedures.
•I acknowledge that each practitioner within the demonstration booth must be registered in California and for reciprocity has not performed body art for
more than 5 consecutive days or 15 days total in a calendar year outside of the county of his/her registration.
• I understand that failure to meet the conditions identified in this notification or failure to comply with requirements set forth in The Safe Body Art Act(California Health and Safety Code commencing with Section 119300) and Alameda County Ordinance may result in the suspension of my approval to
operate and/or may result in an administrative fine.
• I understand that once the application is reviewed, the application fee is non-refundable.
Print
Name:Phone: ______________________
Signature: Date: _______________________
FOR OFFICIAL USE ONLY
FA# __________________________ PR# __________________________
AMOUNT PAID: _________________ DATE PAID _____________________
□APPROVED INSPECTOR’S NAME: __________________________________
□NOT APPROVED DATE: _____________________________________________
Ronald Browder, Director of Environmental Health
Phone: (510) 567-6790 Fax: (510) 337-9234
September 2018