Laserfiche WebLink
x San Joaquin County 1868 East Hazelton Avenue <br /> nVlronntental Health Departmen Stockton, CA 95205 <br /> a" Tel:(209)468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ Fax: (209)464-0138 <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 /> BrandingPermanent Cosmetics Z 1 <br /> E VI <br /> Ii. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES.Check all that apply. R 1T ERV/It TH <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 nnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> if <br /> NAME: — ® t <br /> Phone: <br /> HOME ADDRESS: Email: C� <br /> city: State: Zi County: <br /> Date of Birth: ( � . Gender: r M or M (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilf Name: Owner: <br /> Address: , tJ <br /> Evidence of Six-months of Related Experience <br /> Facili Name: T Owner: <br /> Address: <br /> Service You Provided: <br /> Su ervisor Name and Contact Information: C{ <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed:- <br /> om leted:C)Li `1 t TrainingProvided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> i Certification of Completed Vaccination 3[Z]Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4CEIVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Une 'T1 -P (A <br /> Location address: 11 l l @( a )•? Suite <br /> Cu: State: . Zi Count 1 <br /> OwnerL Contact: - Phone Fax: q <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 t to the b t f in knowJedge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: - Title: <br /> 2 <br />