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Home My WebLink Aboutbodyart-temporary-event-facility-applicationPage 1 of 2 Body Art Temporary Event Facility Application BODY ART TEMPORARY EVENT FACILITY APPLICATION TYPE OF SERVICE: TYPE OF PERMIT: TATTOO BODY PIERCING PERMANENT COSMETICS BRANDING EVENT SPONSOR | SEE FEE SCHEDULE MAKE CHECKS PAYABLE TO ALAMEDA COUNTY EVENT INFORMATION NAME OF EVENT: DATE(S): MONTH ______DAYS _______ TO _______ YEAR NAME OF EVENT MANAGER: CONTACT PHONE NUMBER: TIME(S) OF EVENT: “Sponsor” means an individual or business entity, including an event coordinator or manager, responsible for the organization of a convention, trade show, or other temporary event that includes a body art demonstration booth. A sponsor may also be a body art practitioner. FULL LEGAL NAME (Sole Owner, Partnership, Corporation, etc.): PHONE NUMBER: BILLING ADDRESS: CITY: STATE: ZIP CODE: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMAIL: LOCATION NAME: LOCATION PHONE NUMBER: NAME OF LOCATION MANAGER/ OWNER/ REPRESENTATIVE: CONTACT EMAIL: CONTACT PHONE NUMBER: LOCATION ADDRESS: CITY: ZIP CODE: SITE PLAN NUMBER OF BODY ART BOOTHS Submit a site plan showing the general layout of the event indicating location of the following: 1.Body Art Demonstration Booth(s) 2.Water Supply 3.Toilet and Hand Washing Facilities 4.Trash Disposal Containers (quantity) 5.Location of Decontamination/Sterilization Area(s) (quantity) 6.Back‐up Supplies 7.Hand Wash Stations (quantity) Body art demonstration booth permit fee: $141 per booth (plus inspection fee – hourly rate) Total number of booths performing body art No: All body art booths using pre‐sterilized, disposable instruments/needles? Yes No If “No”, please complete “Decontamination/Sterilization Area” section below. BODY ART DEMONSTRATION BOOTHS Body art demonstration booths must be located within a building, with a partition at least 3 feet high to separate the procedure area from the public, and equipped with adequate light and a sharps waste container. The area within the booth must provide at least 50 sq. ft. of floor space for each practitioner’s work station. DECONTAMINATION/STERILIZATION AREAS TYPE OF SINK: PERMANENT PORTABLE PORTABLE SERVICE COMPANY NAME: _____________________________________________________________________________________________________________ ADDRESS: CITY: ZIP CODE: PHONE NO: ULTRASONIC AUTOCLAVE DATE OF LAST (MODEL): _____________________________ (MODEL): _____________________ SPORE TEST: ______________________ Is the decontamination/sterilization area operated by the event sponsor? Yes No Not applicable – Explain ______________________________________ • If “Yes”, provide a copy of the procedures for decontamination area, log book with records of each load including date, contents, exposure time and temperature, integrator results, and spore test results onsite. • If “No”, provide name(s) of party responsible with contact information. • Provide a copy of current bloodborne pathogen (BBP) training certification for each employee working in the decontamination area. Ronald Browder, Director of Environmental Health Phone: (510) 567-6790 Fax: (510) 337-9234 _______________ September 2018 Page 2 of 2 Body Art Temporary Event Facility Application BODY ART BOOTH HAND WASHING STATION The following is required for each hand washing station: 5‐gallons or more of water accessible via spigot, liquid soap, single‐use towels and a wastewater collector/ holding tank. Up to two booths may share a hand washing station. The location of shared facilities must be approved by the local enforcement agency. Number of hand washing stations: __________________________ Hand washing stations will be provided by: Event Sponsor Body Art Operator Service Provider Name: Service Provider Address: PUBLIC TOILET FACILITIES Number of Toilets: _________________________ For multi‐day events, how often will toilet facilities be cleaned? ___________ times/day Number of hand washing sinks: Warm water available (temp. of at least 100°F)? Yes No WASTE DISPOSAL Number of trash containers per booth: How often are trash containers emptied? times/day Number of sharp containers per booth: Provide a copy of the agreement with the company responsible for proper removal and disposal of all sharps waste containers. Provide the sharps waste hauler information. If mail back systems are being used, list company name and information. Name: ________________________________________________________________________________________________________ Address: ______________________________________________________________________________________________________ Telephone: ____________________________________________________________________________________________________ EVENT SPONSOR ACKNOWLEDGEMENT •I understand I shall provide a list of all booth operators participating in the event; to have back‐up supplies available for purchase; and post in a conspicuous place the name, telephone number, and directions to an emergency room near the event. •I understand that it is the sponsor’s responsibility to ensure that all body art practitioners who will be participating in the event must have a valid Practitioner Registration from a California jurisdiction. •I have completed the application to the best of my ability. I understand that I may be asked to provide additional information in order for the application to be approved and that the information provided is considered part of the application. I understand that failure to provide required information will delay or prevent approval of the event. •I understand that failure to meet the conditions approved in this application and/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 approval to operate the event, suspension of the approval to operate the affected body art booths, and/or may result in an administrative fine. •I understand that I am responsible for obtaining approval from all applicable agencies. •I hereby certify that all statements made in the application and information in the attached event sponsor check list are true and correct. •I authorize investigation of all matters contained in this application. •I agree to operate this temporary event in accordance with all applicable state and local regulations regarding body art procedures and permit requirements. •I understand that once the application is reviewed, the application fee is non‐refundable. Print Name ______________________________________________________________________ Phone No. _____________________________ Signature ______________________________________________________________________ Date __________________________________ FOR OFFICIAL USE ONLY FA# __________________________ PR# __________________________ AMOUNT PAID: _________________ DATE PAID _____________________ □APPROVED INSPECTOR’S NAME: ____________________________________ □NOT APPROVED DATE: _______________________________________________ September 2018