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• ? "° San Joaquin County • 1868 East Hazelton Avenue <br /> 3 Environmental Health Department Stockton,CA 95205Tel: (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 /> QTattooing MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> EDBranding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ipjAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> Pynnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: '^ <br /> NAME: Phone: .HG <br /> —G <br /> HOME ADDRESS: Z, Email: t_ (, <br /> City: L State: Zip: O Count <br /> Date of Birth: 0 7-7 Gender: M or ft (circle one) <br /> Identification Type: r7rDrivers License M10ther Identification No.: 3 <br /> Facility where Body Art Services Will be Provided Inn �/Vb`l�/ `^ p <br /> FacilityName: ' (9er: ' C/ doove* <br /> Address: LA I C 751�, <br /> Evidence of Six-months of Related Experience <br /> LFaacilityName: Owner: VIA-4-il Coress:vice You Provided: 1 /�ervisor Name and Contact Informatio L�Cj 1- <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4[ZlVaccination Declination <br /> IV.FACILITY LOCATION (P:(Attach additional sheets as ecejia&r�y) j� <br /> 1.BUSINESS NAME: � +! �t� l (J(, dit <br /> Location address: AeU N Suite: <br /> City: 4m CA Lj6n State: Zi 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 safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> 1 - - 13 <br /> Print Name: Title: VV fler <br /> LOW <br /> 64, <br /> Art <br /> ,.� ,.. -,. .., s. <br /> "f 2 <br />