Laserfiche WebLink
" • San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> " 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 /> Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding 'Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[4Annual Body Art Practitioner Registration 3r—lMechanical Stud and Clasp Ear Piercing Notification <br /> 2�Annual Body Art Facility Permit <br /> III.APPLICAN INFORMATION: <br /> NAME: / Phone: <br /> HOME ADDRESS: Z&& Email: 714.177j', i t!E'er <br /> Cit : State: _ zip: �' Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: /.�2- ' " ;7 i�, Gender: F r M (circle one) <br /> Identification Type: 04brivers License MOther Identification No.: <br /> Facility where Body Art Services WiliLpb_e Provided <br /> r <br /> Facility Name: Owner: b <br /> Address: <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 Training: Submit Certificate <br /> Date Com leted: (o Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated 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: 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 to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(RENS): Date Entered: <br /> if 2 <br />