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• • <br /> San Joaquin 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 /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing QBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[MAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 214 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION:. <br /> NAME: 12jaw RC�wePhone: t) <br /> HOME ADDRESS: D-1 Email: RV 1• C 01(1 <br /> Ci : State: C 4 Zi County: S A N <br /> will <br /> Date of Birth: 3`I Gl Gender: M o (circle one) <br /> Identification Type: ImDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: e W Owner: E dd <br /> Address; w i ( 2 El C <br /> Evidence of Six-months of Related Experience <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 /> 1 Certification of Completed Vaccination 3ContraIndicated for Medical Reasons <br /> � <br /> 2�Laboratory Evidence of Immunity 4[:Jvaccination 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: Zip; Cou nty: <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 governin a body art practices, r practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t t the beat of my kno a and belief the statements made herein are true and correct. <br /> Signature: Date: Lo " Cyr/Z <br /> Print Name; f Title: (J(,✓it AY <br /> j <br />