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• San Joaquin County • 1868 East Hazelton Avenue <br /> Environmental Health De artment Stockton)CA -3220 <br /> i <br /> P 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 aMechanical Stud and Clasp Ear Piercing <br /> Branding -=ermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2'TElAnnual Body Art Facility Permit <br /> III.APPLICANT INFO MATION: <br /> NAME: Phone: <br /> <br /> <br /> Date of Birth: Gender: M or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 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 /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4Mvaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: qawn Qum <br /> Location address: 0 USuite: T, if ` <br /> City: State: c A Zip: -:1 Q County: <br /> Owner Contact: 61anaaPhone/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 o my knowled and belief the statements made herein are true and correct. <br /> Signature: —" --- Date: w <br /> Print Name: �(7 Title: <br /> 44 <br /> f2 <br />