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rw fan Joaquin County <br /> 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tei: (2 4 8-3420 <br /> Fac ( 8 <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 /> ttooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> I'MAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> -14 <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT;INFORMATION: (' (y <br /> NAME: J Phone: Q So <br /> HO ME ADDRESS: �� Email: <br /> Ci State Zi Coun <br /> BOE�Y DIRT CTTTIONER`ONLY <br /> Date of Birth: } Gender: M o( M circle one) <br /> Identification Type: 171IDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided p <br /> Facili Name: r(� C'_, Owner:/� <br /> Address: 5 <br /> Evidence of Six-months of Related Expe nce <br /> Facili Name: + A0, Owner. ` , I Alt <br /> Address: <br /> Service You Provided: <br /> Su ervisor Name and Contact Information: l <br /> Bloodborne Pathogen Training:Submit Certificate nn (` ff <br /> Date Completed-: Z('� 2 TrainingProvided b :A ► -4 f IGL1 <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 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: /) <br /> Location address: Suite: <br /> city: A 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 Notif=ication 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 to the best of my knowledge and belief the statements made herein are true and correct. <br /> EFOROFFICE <br /> Date: 2 0 ,I <br /> Title: <br /> USE ONLY <br /> ): Fees: Authorized by(RENS): Date Entered: <br /> If 2 <br />