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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> 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. PROCED RES TO BE PERFORMED:Check all that apply (see back for dfi ions) <br /> Tattooing OcK Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> I[TL]Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> -fn �20q Z/ I <br /> NAME: ` V Phone: <br /> - <br /> HOM RESS N Email ® 1 <br /> Cit State: Zi : Count : <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where y Pert Servic Wit P ov' ed <br /> l�Facility Name: 1 Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> FacilityName: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: TrainingProvided by: <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 tificati n agrees to operate in accordance with all applicable state and local <br /> requirements 0 v in s bo a practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby ce of that t o knowledge and belief the statementsma e herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If 2 <br />