HomeMy WebLinkAboutbodyartfacilitypermitapplicationformTYPE OF APPLICATION: □ NEW □ RENEWAL
TYPE OF SERVICE: □ TATTOO □ BODY PIERCING □ PERMANENT COSMETICS □ BRANDING
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Body Art Program
Alameda County Department of Environmental Health
Solid/Medical Waste Management
1131 Harbor Bay Parkway, Alameda, CA. 94502 Phone: (510)567-6790 Fax: (510) 337-9234
https://deh.acgov.org/index.page
BODY ART FACILITY PERMIT APPLICATION FORM
(INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED)
The facility owner must keep an updated list of
practitioners and notify this Department of status changes within 30 days.
PRACTITIONERS NAME PR# PRACTITIONERS NAME PR#
I hereby certify that all statements made in the application and information in the attached documentation are true and correct. I agree to
operate in accordance with all applicable state and local regulations. I agree to maintain a current Infection Prevention and Control Plan.
SIGNATURE: DATE:
PRINT NAME / TITLE:
Signature on this form indicates agreement to comply with all applicable statutes. Fee is in accordance to Title 6 of the Alameda County Ordinance Code.
FOR OFFICIAL USE ONLY
ENVIRONMENTAL HEALTH SPECIALIST: □ APPROVED □ NOT APPROVED DATE:
FA# PR#
AMOUNT PAID: DATE PAID:
FACILITY INFORMATION: FACILITY NAME: FACILITY ADDRESS: CITY: STATE: ZIP CODE:
BUSINESS OWNER(S) NAME: BUSINESS OWNER(S) ADDRESS: CITY: STATE: ZIP CODE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: BUSINESS PHONE NUMBER: HOME / CELL PHONE NUMBER: REQUIRED DOCUMENTS FOR FACILITY PERMIT: □ Facility Infection Prevention and Control Plan □ Plan Check Completed □ Body Art Practitioner Registration(s) □ Consent Form / Medical Questionnaire
□ Permit Fee □ Post Procedure Instructions
OTHER REQUIRED DOCUMENTS: □ Business License □ Video of Setup and Break Down of Body Art Procedure for Each Body Art Practitioner