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1868 East Hazelton Avenue <br /> San Joaquin County <br /> • � � <br /> Environmental Health Department Stockton,CA 95205Tel: (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 /> 1�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICINJ INFORMATIO <br /> NAME• ar rrlo) <br /> n Phone: <br /> HOME• DRESIS..: w �54Email: D�1 <br /> City: \ State: Zi County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: o Gender: F or M (circle one) <br /> Identification Type: LM Drivers License MOther Identification No.: `Z <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: `( �� Owner: <br /> Address: C <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 /> 1oCertification of Completed Vaccination 3r--IContraindicated 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: <br /> Location address: C4 Suite: <br /> Cit State: Zip: Count V� \l1 <br /> Owner Contact: QJ 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 Piercinot• ication and agrees to operate in accordance with all applicable state and local <br /> requirements go r i fe body art prac • es r practices governing mechanical stud and clasp ear piercing. <br /> I hereby certif t t t e best of my k wl a and belief the statements made herein are true and correct. <br /> Signature: Date: - 2 <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(RENS): Date Entered: <br /> f2 <br /> I <br />