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San Joaquin County 1868 East Hazelton Avenue Environmental Health Department Stockton -3220 Tei: (209)) 4 4668-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) . Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing ®Branding ®Permanent Cosmetics I1. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ITMAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification 2®Annual Body Art Facility Permit � W i� am vFMIi�+ • o . IV. FACILITY LOCATION (S): (Attach additional sheets as neces$ipry) 1. BUSIIJESS :u !Licy i •' 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the est of my knowledge and belief the statements maa hejelnare true and correct. Signature: Date: 17— / Print Name: C itle: Date of Birth: % Gender: F r MM (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facili Name 7_ D S -r- Owner: V� Address: l T'S S -70 Evidence of Six -months of Related Experience Facili Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation I[Z]Certification of Completed Vaccination 3®Contraindicated for Medical Reasons 2®Laboratory Evidence of Immunity 4vaccinatlon Declination IV. FACILITY LOCATION (S): (Attach additional sheets as neces$ipry) 1. BUSIIJESS :u !Licy i •' 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the est of my knowledge and belief the statements maa hejelnare true and correct. Signature: Date: 17— / Print Name: C itle: