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San ]oaquin County • Stockton,CA 95205 <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Tel: (209)468-3420 <br /> R` <br /> I <br /> 4 Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 11MAnnual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> i <br /> III.APPLICANT INFORMATION: <br /> NAME: Phone: q <br /> <br /> <br /> Date of Birth: / /9S7 Gender: Anor MM (circle one) <br /> Identification Type: MDrrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: ,(J Owner: Q` <br /> Address: 0 D ?E .S .OeXW,17 <br /> Evidence of Six-months of Pelated Experience <br /> Facility Name: / Owner: h� <br /> Address: <br /> Service You Provided: T r <br /> Supervisor Name and Contact Information: 49186wm Alff.,F101-- <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted::3 ?dZ Training Provided by: 33d /2 —)2/•x6'd5 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Co Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach//additional sheets as necessary) <br /> 1. BUSINESS NAME: All <br /> b <br /> Location address: // /�. ir, `jib el 4 Suite: <br /> City: 5 j State: Zi Zd County: - <br /> Owner Contact: �QriJ Y Phone Fax: p <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/ Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: 12A 6414-del ZkAP a4Title: t��y�ii/Q� L�m �f�fay[p-�c�d 'dofi�liCl <br /> f2 <br />