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q y. 1868 East Hazelton Avenue <br />,a� ����,�������\ Stockton, CA 95205 <br />Enuirfbnniental Health Department Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY AR.1 FAC`SLE' T Y AND PRACT IT I0M ER REGIST ATHOM/ <br />MECHANICAL STUD AND CLASP EAR PIEPCXMG MOTIFICAT nGM <br />I. PROCEDU a d® BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing ®Body Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding F==IPermanent Cosmetics <br />II. REQ=nnual <br />S RATIO3,PERMIT, ORNOaEFICATIQMFEES.Check all ''thatapply. <br />1Body ArtPractitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />0-4 <br />2 Annual Body Arc Facility Permit <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: C%?/ Genderr: F /oar (circle one) <br />Identification Type: Drivers Lcense Other Identification No.: (� V <br />Facility iefhere Body Art Services iii be Provided <br />Facility Name: 9 Owner: <br />Address: <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; SuNnit Certificate <br />Date Completed: Z140113Training Provided by: Ctil& <br />Hepatitis B Vaccination Status: Choose One and Submit Documentati® <br />1 Certification of Completed Vaccination 3 Co ` indicated for Medical Reasons <br />2 -[=Laboratory Evidence of Immunity 4 accination Declination <br />IV, FACILITY LOCAT IOM (S): (Attach additional sheets as necessary) <br />I. BUSINESS NAME: <br />Location address: <br />Pho <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City' <br />State: Zip: County: <br />Owner/ Contact: <br />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 <br />and agrees to operate in accordance with all applicable state and local <br />requirements governi <br />`e body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby Certify .t 't <br />bes G�- r .-novulecee and C anew the --tatenzents made herein are tree and cu vact. <br />Signature: <br />Daae: <br />Print Name: �WI�Icj <br />Title: <br />�FAR fiFFlCh USE DPdL`f--------------------------- — --- ------ �Prograrn (PE): Fees: Authorized by (RENS): Date Entered: <br />rtL--vTil i <br />