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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 /> ECHAICAL 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 Pierci <br /> Branding ED Permanent Cosmetics <br /> II. REQUIR D REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> IEFIVVI2019 <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Pierccin <br /> 2 S <br /> Annual Body Art Facility Permit 'TNu "®SFRV/ CTH <br /> III. APPLICANT INFORMATION: / w <br /> NAME: Phone: e <br /> HOME ADDRESS:: s ciffes Email: ol i&ue 13 n co r0 rkai . <br /> Cit : ( State: 6 A Zi County: W <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 'T Gender: M or (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided r <br /> FacilityName: Owner: ck <br /> Address: P(p kd v, . <br /> Evidence of Six-months of Related Experience // Q <br /> Facility Name: fit. �` Owner: V\ v�'�l <br /> G <br /> Address: -� - <br /> Service You Provided: tgodw <br /> Supervisor Name and Contact In ormation: <br /> Bloodborne Pathogen Trai mg: Submit Certificate <br /> Date Completed: Training Provided by: i�Gl f <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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: r Date: / ! <br /> Print Name: f Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): 4110 Fees: Authorized by (RENS): Date Entered: <br /> If2 <br />