HomeMy WebLinkAboutbodyartpractitionerregistrationformBody 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 PRACTITIONER REGISTRATION FORM
□ TATTOO BODY PIERCING PERMANENT COSMETICS BRANDING
TYPE OF APPLICATION:
NEW RENEWAL
GENERAL PRACTITIONER INFORMATION:
FULL NAME (Please Print): (Last Name) (First Name) (Middle Initial) HOME ADDRESS: CITY: STATE: ZIP CODE:
MAILING ADDRESS: CITY: STATE: ZIP CODE:
EMAIL ADDRESS: DATE OF BIRTH (Must be 18 or older):
HOME PHONE NUMBER: CELL PHONE NUMBER:
Are you a registered practitioner in Alameda County? □ Yes □ No If Yes, please provide PR#:
Are you registered as a practitioner in another city or county in California? □ Yes □ No If Yes, what county?
REQUIRED REGISTRATION DOCUMENTS: □ Hepatitis B – Hepatitis B Vaccination / Immunity / Boosters / Declination (Please circle ONE and provide supporting documentation)
□ Bloodborne Pathogen Training Certification (Provider must be on the approved list) – Expiration Date:
□ Passport Size Photo (2”x2”) or Electronic Photo for the Registration Card □ Consent Form / Medical Questionnaire □ Copy of Driver’s License or other Government Issued ID Card □ Infection Prevention Control Plan (IPCP) □ Post Procedure Instructions □ Permit Fee
OTHER REQUIRED DOCUMENTS: □ Business License □ Video of Setup and Break Down of Body Art Procedure
NAME OF BODY ART FACILITY #1:
FACILITY ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: PHONE NUMBER:
NAME OF BODY ART FACILITY #2:
FACILITY ADDRESS: CITY: STATE: ZIP CODE:
EMAIL ADDRESS: PHONE NUMBER:
Note: INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Facilities must be permitted otherwise your application will not be processed and fees may not be refundable. Practitioner registration is not transferable from one location to another. A new application and permit fee must be submitted when working at a new location. 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 certification in Bloodborne Pathogens Exposure Control Training (Section 119307).
SIGNATURE: PRINT NAME: DATE:
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: