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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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercini!! <br /> Branding Permanent Cosmetics N 0, <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. 7,� <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notificati WCj,% \ <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: A,V'G11 c� Phone: <br /> HOME ADDRESS: Email: r �J^Lct <br /> Cit :Tr State: Zi Count J--'Aq L4 l <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: >b 19V Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: (A Owner: �s v rut <br /> Address: 145 W L D <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 /> 1®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 accination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: QjY K <br /> Location address: L��J �1 LD � l r 1n53 Suite: <br /> T— �� �� <br /> City: T�/ ,ilq State: Zip: County: I, <br /> Owner/ Contac) Phone/ Fax: r® Ll:� 3 <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: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: _ Authorized by(REHS):'� ate Entered: <br /> If2 <br />