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San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> e..� ►' Environmental Health Department 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 /> :MTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> 013randing Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: , <br /> NAME: h f53<'e— Phone: �� QD�✓�� <br /> <br /> � <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �j Gender: F or M (circle one) <br /> Identification Type: vers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: a � _�, l.. Owner: A �� <br /> Address: C'T E-4, ? <br /> Evidence of Si -months of Related Experience I` <br /> Facility Name: V1 S Owner: <br /> Address: c:�DA <br /> Service You Provided: <br /> Supervisor Name and Contact Information: 17 <br /> Bloodborne Pat o��g((e ^Training: Submit Certificate <br /> ' 7 <br /> Date Com lete / 'D Training Provided b 4�Ui o , <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 4F�accination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: -� � j?(�(; w{-}-c 0 <br /> Location address: jt;(c� -�� C Suite: <br /> City: �.u_vC./y State: C-'b Zip: °r J'7y��i County: <br /> Owner/ Contact: Ar-to–". Phone/ Fax: ��a� ' r� '� -51 <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 he best of wledge and belief the statements mad herein ar <br /> j e true and correct. <br /> n <br /> Signature: Date: 2 <br /> Print Name: t Lk�X0: is; Title: + <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If 2 <br />