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San Joaquin County • 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> rte _ 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 /> nTattooing MBody Piercing OMechanical Stud and Clasp Ear Piercing FEB <br /> Branding NPermanent Cosmetics ENWI�O 1�?Q <br /> Mr <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. ITCS TF/ <br /> 1�Annual Body Art Practitioner Registration 3r--IMechanical Stud and Clasp Ear Piercing Notification <br /> 2[_]Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: ` r <br /> NAME L Phone: �ji6 I�(,��'(,- `5.1)-9 <br /> HOME ADDRESS: Email: <br /> Cit State: Zi 3 Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or nM (circle one) <br /> Identification Type: LZrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> s mak- S�� 5 r <br /> Facility Name: lJue(, L, caner: <br /> Address: R Vj - <br /> Evidence of Six-months of Related Experienc <br /> a CC t� <br /> Facilit Name: fL'�' e'r A-01e L� rte( C L erg `G'C ( I <br /> Address: <br /> u' <br /> Service You Provided: J <br /> VI <br /> Supervisor Name and Contact Information: 64ctuj <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Trainina Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1JE3'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: <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 tO the f my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 21 C <br /> Print Name: %fA n ��' Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): 4110 Fees: Authorized by (REHS): 9183G Date Entered: <br /> If 2 <br />