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San Joaquin County ® 1868 East Hazelton Avenue <br /> StoEnvironmental Health Department el: (209)kton, 46 -3220 <br /> 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 Mechanical Stud and Clasp Ear Piercing <br /> ®Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICAt4T INFORMA YON: <br /> NAME: 4- Phone: LP v <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �® Gender: F r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Bod ArtS vices Wi 1 be Pr vWed r <br /> Facilit Name: UZ t Owner: <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 Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1Certification 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: 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 gover 'ng safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certifth o my nowledge and belief the statements made herein are true and correct. <br /> Signature: _ _ Date: _ <br /> Print Name: _ Title: <br /> FOW6FFICE USE ONLY <br /> Program (PE):" Fees: Authorized by(RENS): Date Entered: <br /> If2 <br />