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?" " 5 • San Joaquin County • 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental HDepartment De artment StocktonTel: (209})4 4668--34203420 <br /> n>< 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 oBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding oPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Phone: Z7i'_ <br /> HOME ADDRESS: `Z Email: 1 'C-0l71 <br /> City: State: Zi90-09County: ifl <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 02— M91 Gender: F or MM (circle one) <br /> Identification Type: MDrivers License rMOther Identification No.: � <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1Y�� Owner. 'r`(WAO �1 <br /> Address: 0.Cifrl C �/�° Ula <br /> Evidence of Six-months of Related Experience <br /> Facility Name: 1 Owner: L) <br /> Address:kA <br /> Service You Provided: <br /> Supervisor Name and Contact Information: t C1?' <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Li 1-7 ftkAq Training Provided b : `bid i i S6\a Of"S <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> Hepatitis <br /> of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[DVaccination 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: Date: <br /> Print Name: Title: <br /> MR OFFICE tib O .Y <br /> m(PE): Fees: AuthgDate Entered: <br /> if 2 <br />