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San Joaquin County , 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> K,. <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 Mechanical Stud and Clasp Ear Piercing <br /> ®Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual 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: Phone _ <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: y2 I Gender: F or M (circle one) <br /> Identification Type: Mbrivers License Other Identification No.: <br /> Facility where Body�#Art Services Will be Provided q <br /> Facilit u <br /> Name: qi Pi Owner: A(04�;`i, <br /> Address: <br /> vidence 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 1_ <br /> Date Completed: 3 If / �a Training Provided by: ®®W <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 4 99 <br /> Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: aff 61&09 <br /> Location address: vi ka (� Suite: <br /> Cit State: CA Zi 6 Count : je"n <br /> Owner Contact: WdCLrPhone/ 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 certi&th t' the est my kno led a and belief the statements made herein are true and correct. <br /> Signature: __.__ Date: �' 1 C2 _ <br /> Print Name: Title: <br /> FOR OFFICE USEONh:Y <br /> Program (PE): p Fees: A OGS Authorized by(RENS):' ate Entered: <br /> If 2 <br />