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San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> nVironmental Health Department Stockton,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 /> E]Tattooing [MB. Piercing Mechanical Stud and Clasp Ear Piercing <br /> d <br /> [:]Branding �fPerm' anent Cosmetics E:3 <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> itMAnnual Body Art Practitioner Registration 3[Z]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: '0 <br /> NAME: fE��� &') Phone: <br /> <br /> <br /> Date of Birth: H111 (circle one) <br /> Identification Type: ,j_..jDrivers License [MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: ® <br /> Owner: <br /> ad2l <br /> Address: If2 I&I d0a.XL -S: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> SuRervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate Wve-TraK'\ <br /> Date Completed: I I �e (:2-0113 Trainiag&2jjqjg_U: (� -i ni R2 (c) <br /> Hepatitis 0 Vaccination Status: Choose One and Submit Documentation <br /> 1[ZCertification of Completed Vaccination 3[:3 Contraindicated for Medical Reasons <br /> 2[MLaboratory Evidence of Immunity 4[Dvaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: W <br /> Location address: .V_r� Suite: <br /> Citl State: Zio: County: <br /> Owner/ Contact. Phone 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 th to:the best of my knowledge and belief the statements made herei are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> gg <br /> T2 <br />