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San Joaquin county 1868 East Hazelton Avenue <br /> % '-' �> Environmental Health Department Stockton,CA 95205 <br /> x Tel:(209)468-3420 <br /> Fax:(209)464-0133 <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 /> 1Lie— <br /> Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT IKFORMAT N: <br /> NAME: /3!1!�!Aj'j a®ov Zt I A-- s- 4�9-5-713 <br /> Phone: <br /> HOME ADDRESS: ` G® s Email: f� <br /> City: T State! zipCounty cS'/9/U (111J <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F r M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: h Owner: f <br /> Address: // 7WAf yS 3�r!o <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> [SupervisorName and Contact Information: <br /> oodburna Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certlflcatlon of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2M Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: ®"!lAtett �f <br /> Location address: <br /> Suite: <br /> City: e• Zip County <br /> Owner/Contact: Phone/Fax: <br /> 2.BUSINESS NAME: <br /> Location address; <br /> Suite: <br /> City: -- State <br /> 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 th to Best o —knowledge and belief the statements made herein are true and correct. <br /> Signature: Awl <br /> Date: <br /> Print Name; la 09Title: Or WA/ <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Z�� Authorized by(RENS): ate Entered: <br /> if 2 <br />