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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton)46 -3225 <br /> p Tel:(209Stockton)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ftlTattoolng MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> IMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> fflAnnual Body Art Facility Permit <br /> s� <br /> III.APPLICANT INFORMATION: \ p <br /> NAME: ( p'ss-F-- 1 V V t7 Phone-CZCn <br /> D 1 '92 CD I I L� <br /> HOME ADDRESS: 31)"1 <br /> f i 7 I sT ST Email a.1 MMU S;:- CK4&G k(A Li. <br /> Cit State Zi Coun Q <br /> S W <br /> BOD AR�PRAC}TITIO ENEN _ flN t - _ _ � <br /> Date of Birth: Gender: M o"r. M (circle one) <br /> Identification Type: MDrivers License Other Identification No,: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner. L <br /> Address: aC roN <br /> Evidence of Six-months of Related Experience <br /> FacilityName Owner: <br /> Address: S C <br /> Service You Provided: O <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 /> 1MCertiflcation of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[::]Vaccination 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 thajXo the b t f y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> P <br /> aa (PE),. a s. <br /> orized b E S,): Da e E ere,'` <br /> f2 <br />