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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <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 /> 1.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 /> IrUlAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: r► ®� <br /> NAME: <br /> <br /> <br /> <br /> Date of Birth: (f Gender: F I or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: 1. Owner: ®" <br /> Address: <br /> Evidence of Sex-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 /> Ad <br /> Date Completed: 02offo Training Provided by: AMCr1rA#jet 1 ( Z7At <br /> 7 <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):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: r: UE: <br /> Location address: 16'13 Q Suite: <br /> City: "1 State: Zi Coun AJ 11l( <br /> Owner/Contact: Phone/Fax: a – &57 <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 my kk ledge and belief the statements made herein are true and correct. <br /> Signature: ,L®" Date: <br /> Print Name: ttQIV Title: OWALM <br /> R OFFICEgUSE'r ONLY _ *"s znt ,, "Ar', t ;ids f ra at t Jgw.a x s <br /> FO , b, - � <br /> Progr� (PE} Fees (�� ` Authorized by(REHS) r Date Entered <br /> ran�, �srTr*."�.��`, ,�.F^,".':! <br /> f2 <br />