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�. San Joaquin County 1868 East Hazelton Avenue <br /> nvironmental Health De artment Stockton,CA 95205 <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 /> MTattooing QBody Piercing aMechanical Stud and Clasp Ear Piercing <br /> Brandingermanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[bAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT NFORMATION: <br /> NAME•. Phone: <br /> HOME ADDRESS: Email: 1 Kc <br /> Ci State: Zi County: <br /> BODY ART PRACTITIONER ONLY l <br /> Date of Birth: Gender: flj or MM circle one) <br /> Identification Type: Drivers License MOther Identification No.: [ �{ <br /> Facility where B y Art Services Will be Pro 'det) Pei <br /> Facili Name: I\ I <br /> caner: 1- `(� <br /> Address: V t J <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: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1QCertification of Completed Vaccination 3EContraindicated for Medical Reasons <br /> 2�Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S)' Attach itional sheets as necessary) <br /> 1. BUSINESS NAME: lh '/ <br /> Location add ess: yr -Df Suite: <br /> City: State: Zil): 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 gov g safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby cern o the be y ovule and belief the statements ad herein are true and correct. <br /> 7Signature: Date: 1111 <br /> Print Name: Title: <br /> FOR OFFICET // <br /> Program(PE): (N Fees: Authorized by(REHS): Date Entered: <br /> f2 <br />