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q y. 1868 East Hazeiton Avenue <br /> , a � ����,��� ����\ stookton,CA 95205 <br /> EnuirfbriniaYi'tal Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY AR.T FACILE'T Y AND PRACT IT I0M ER REGIST ATHOM/ <br /> MECHANICAL STUD AND CLASP EAR PIEPCXMG C OTIFICAT nGM <br /> Z.PROCEDJ a d®BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing ®Body Piercing MMechanical Scud and Clasp Ear Piercing <br /> Branding F==IPermanent Cosmetics <br /> 11.RE PERMIT,EPEE NOTAKFICAT IQM FEES.Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> Z Annual Body Arc Facility Permit <br /> III.APPLICANT F®RF3 Y ZOM: <br /> NAME: ✓T/1 Phone <br /> _ DR S: -T Email: <br /> Cit State: Zi Coun' : <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: a?i Gender: <br /> 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: CA & <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 /> V.FACILITY LOCAT XOM (S):(Attach additional sheets as necessary) <br /> I. BUSINESS NAME: <br /> Location ad I Suite: <br /> City: State: Zip: —! Count : <br /> Owner/Contact: Phone/Fax: fi <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 governi `e body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereG3y Certify.t 't be-s c"rn -rnEovulecee and C alien the statements rnaele herein are tree and cuvvact. <br /> Signature: Date: Id5 ® / <br /> Print Name: Title: <br /> FAR OFFICE USE DPdL`f--------- --------- -- <br /> Prograln (PE): Fees: Authorized by(REHS): Date Entered: <br />