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San Joaquin County 1868 East Hazelton Avenue <br /> "t 68--34203420 <br /> Environmental Health Department Stockton,Tel: (209)468-3420 46 <br /> A 95205 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP R 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 IfPermanent Cosmetics Nj <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> Ow <br /> iLnjAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICAAT INFORMATION: <br /> NAME: a Phone: c) L <br /> HOME ADDRESS: I )o \c y)" Email: e c i�c° CH`s <br /> City: mU c-cp State: Zip County: -sa C cjy-e <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Lk I Gender: F or M (circle one) <br /> Identification Type: X Drivers License Other Identification No.: bel <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: GLK Owner: <br /> Address: &-r <br /> Evidence of Six-months of Related Experience <br /> FacilityName: Co <br /> Owner: rI <br /> Address / <br /> Service You Provided: <br /> Supervisor Name and Contact Information: j <br /> Bloodborne Pathogen Training: Submit Certificate _ <br /> Date Completed: Trainino Provided_L:: f lain in <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 4E4Vaccination Declination <br /> IV. FACILITY LOCATION (S)•(Attachtional heets as necessary) <br /> 1. BUSINESS NAME: addi (j o 6L <br /> Location address: 6-rff 9T Suite: <br /> City: G State: rA Zip: ount <br /> Owner/Contact: C/ ( '�/ 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 th to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 1 <br /> Print Name: AA41 &tdenei Title: 8W ln <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> Rev T 11 If2 <br />