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San*Joaqu(n County 1868 East Hazelton Avenue <br /> Stockton CA 95205 <br /> Environmental Health Department Tel: (209;468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1. PROCEDLJRES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> [ZTattooing [::]Body Piercing OMechanical Stud and Clasp Ear Piercing <br /> [::]Branding [I]Permanent Cosmetics <br /> 11. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[Z[Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAME: Phone: <br /> HOME ADDRESS: c,Yr ee.Y— n!d\i P, Email: .3M TL <br /> City: K State: aL zip: County: <br /> 11116 i B <br /> OW <br /> 0 N W lE�NW <br /> Date of Birth: Gender: F or (circle one) <br /> Identification Type: CnDrivers License [DOther Identification No.: <br /> Facility where Body Art Ser_vlces Will be Provided <br /> Facility Name: i I�CQ=3 1-)Y) f:2, �'k�o o Owner: V rAno\x-V Y) <br /> A_ddress-. <br /> Evidence of Six-months of Related ixperience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1EDCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2M Laboratory Evidence of Immunity 4Vaccination Declination <br /> IV. FACILITY LOCATION (S).(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME; <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Z12: County: <br /> Owneil,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 b dy art practic or practices goveming mechanical stud and clasp ear piercing. <br /> I hereby certify t�ht theb y k ledge and belief the statements made herein are true and correct. <br /> Signature: I A Date: 2 �7 <br /> Print Name: F. G Title: Z:L_,c� <br /> TVWN ow <br /> 11111111ill! 01141111, <br /> E 1 <br /> AN 5 e � <br /> 2 <br />