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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 /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> loAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME:, e� C-,cAr r," Phone: <br /> HOME ADDRESS: tj S�- / Email' l i �Gli J . com <br /> Cit C State: Zi :41 � County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: [ ca y'?, Gender: M or nM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Sec.d �� Owner: <br /> WI-A <br /> Address: A V _ <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: 7i � \ TrainingProvided b t�`�� -I i`\ QC <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification 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: 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 t he best of my knowledge and belief the statements made her in are true and correct. <br /> Signature: tizDate: 0 Z <br /> Print Name: L9 '�- MCC, le, Title: Tot t;,Vv 0 c FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(RENS): Date Entered: <br /> muv 14111 f2 <br />