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p <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Cox: <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 [::]Bgdy Piercing Mmechanical Stud and Clasp Ear Piercing <br /> ®Branding Oyermanent Cosmetics <br /> I1.REQUIR EGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i ` Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION, <br /> NAME: nV, <br /> fl �kAPhone: I <br /> HOME ADDRESS: Jt Email: L`6 <br /> City: �k State: C7r Zip: 1 County: San Ifiot-All <br /> BODY ART PRACTITIONER ONLY <br /> Date of Blrth: Gender: or M (circle one) <br /> Identification Type: rivers License Other Identification No.: <br /> Facility where Body Art epvices Will be Provided i' <br /> FacilityName: Owner: <br /> Address: v CA, CA J <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 Trainin :Submit Certificate <br /> Date Com leted: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 ation 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: 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 t s f my kn ledge and belief the statements ma4e h rein are true and correct. <br /> Signature: Date: + f <br /> Print Name: GIMW Title: V re,6V 1 <br /> FOR OFFICE USE ONLY <br /> Pr'ogram`(PE): Fees: Authorized by(RENS)- Date Entered: <br /> If2 <br />