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San Joaquin County 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton) <br /> Tel:(209))4 468--3420 <br /> { n 6 <br /> %tea Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURESTO BE PERFORMED:Check all that apply(see back for defini°ions; <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. :ZE SUIRED RE61FTRATION,PERMIT,OR 11,10TIFIC ATTON FEES;Check a.. c1hat apply. <br /> 1 nnu s' °ody Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICA T INFORMATION: <br /> NAME: A-1P AS <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F o M (circle one) <br /> Identification Type: PEgDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1 Owner: <br /> Address: / <br /> Evidence of Six-months of R'"d, <br /> Exper ce <br /> t <br /> Facili Name rsa Mnc'-�b� Owner: <br /> Address: W~ <br /> Service You Provided: C —7 <br /> Supervisor Name and Contact Information: 0 CAP <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certiflcation of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®laboratory Evidence of Immunity 4ERgVaccination 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 saf Q&Ly art practi es or fractices governing mechanical stud and clasp ear piercing. <br /> ' <br /> I hereby cer that to a bes w dge d belief the statements made herein are true and correct. <br /> Signature: Date: ®1 <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(RENS): Date Entered.- <br /> MeV 1411 1 <br /> f2 <br />