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1868 East Hazelton Avenue <br /> San Joaquin County <br /> Stockton,CA 95205 <br /> dub <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 /> 1Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 1EAnnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: e <br /> 11 <br /> NAME: Phone: O J (,� <br /> HOME ADDRESS: t Email: . Gt n �, mG ' <br /> City: 'c60 State: Ir_A,T Zip: ) County: Scin Gla✓s_ <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: r MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name:(, Owner: <br /> Address: ®t o �hC 0a <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 /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S): (A®ttach additional sheets as necessary) <br /> 1. BUSINESS NAME: t/, <br /> Location address: &V ( Suite: <br /> City: S°t�ate: Zi : /® ount N <br /> 2 53 <br /> Owner/Contact: �`� �, y 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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that tothe st nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: Z=j'7 <br /> Print Name: ®h—� ter ere-, V Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> Rev 12111 f2 <br />