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San Joaquin County 1868 East Hazelton Avenue <br /> 40 Stockton,CA 95205 <br /> Environmental Health Department 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 /> Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding Eapermanent Cosmetics <br /> II. REQUXRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> i 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 /> NAME: Phone: (( L ®ISIAI�j <br /> HOME ADDRESS: (l) Email: C� ) Gt a/t <br /> Cit State: CP zip: Count : n <br /> a r-i i�P } a thf ' � p� t a � i¢ `Z �r i ' ^`t,7 .. ., ri z 7� ✓y,3 a , >i- h. <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will 4e Provided <br /> Facility Name:P r 'c Owner: <br /> Address: G y-\ C <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: -1 Training Provided 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: plur [ 2<a 0�A +� <br /> Location address: 2 2!�;3 26L24i C Pyle, Suite: <br /> City: State: Ch Zi County: UIY� <br /> Owner Contact: PaL`Cvjo Phone Fax:C <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 certif tha 6 th Amy knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> �rgra � I �t'��s �r �AUtE'tCTrFZe�b, R�� � K 13'd�r�Entered <br /> f2 <br />