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$° San Joaquin County 1868 East Hazelton Avenue <br /> y Stockton, CA 95205 <br /> SlEnvironmental Health Department Stockton, <br /> (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 MPermanent Cosmetics <br /> II. REQUIRED 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: C <br /> NAME: g�(.Q�( f" / =LL <br /> Phone:(2Cq_) :S' 5J " L/ <br /> HOME ADDRESS: / /2 7L/ T. Email: <br /> City: State: Ctl- Zip County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Z T • , Gender: F r M (circle one) <br /> Identification Type: Chrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: nPAms) 2) <br /> Address: t <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 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: ICL V)&2Ca_6 C.LL422 <br /> Location address7' _<-/5 fQ fM [ Suite: <br /> City: M Al State: Zip: County: <br /> Owner/ Contact: �' Phone/ Fax: 2 <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 tdge a belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Q Fees: L Authorized by (RENS): Date Entered: <br /> If 2 <br />