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• San Joaquin County • <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 3220 <br /> p 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 Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[-_—]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Phone: <br /> <br /> <br /> Date of Birth: 1-06- rqyl' Gender: VOPVor MM (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: -AA b <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 b : <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets ans`necessary) <br /> 1. BUSINESS NAME: <br /> Location address re "yA Suite: <br /> Citcj&hState: Zip: Z County: <br /> Owner/Contact: Phone/Fax: <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 Isafe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that he est f owledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: 144, A Title: <br /> All <br /> ww <br />