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g San Joaquin County 1868 East Hazelton Avenue <br /> l A 95205 <br /> nvironmenta' Health Department Stockton <br /> p 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 /> LyjTattooing 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 /> irlaAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLIC NT INF MATIO : <br /> NAME: 1 fPhone: 415 El 225 <br /> HOME ADDRESS: Email: <br /> Ci te: Zi County: <br /> Date of Birth: (� Gender: F or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will a Provided fCt <br /> FacilityName: Vt o a Owner: U"v <br /> Address: SUL <br /> r 1 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Sb(' Owner: k�l� <br /> Address: Ih <br /> Service You Provided: <br /> Supervisor Name and Contact Information: b M f6ll <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: / / Training Provided b o ' n i <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 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 t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: �2j— <br /> Print Name: 1 Title: <br /> if 2 <br />