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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> �a nvironmental Health Departmenl� 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 Mmechanical Stud and Clasp Ear Piercing <br /> Branding IDPermanent 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 /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: r� <br /> NAME: cnary- s(cil� �rl'�e Phone: (ALAI )405-47(o�_3 <br /> HOME ADDRESS: St Email: <br /> City: 5' 6)LK1 Ur1 State: rA Zip: C5dog County: bCtir JiC�f�,Ui►rl <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: U - — Gender: M or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: 9601 0 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: -1-n 4 `J Pl Owner: I11 <br /> Address: Q-1,3q a <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: i <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 todie b6st of my;kti ledge and belief the statements made herein are true and correct. <br /> .-r <br /> Signature: `i Date: 30 Y< <br /> Print Name: Gti. CkA Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> ' If 2 <br />