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" San Joaquin County 40 1868 East Hazelton Avenue <br />Environmental Health Department ckton, CA 95205 <br />Tel: (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) — - 5 <br />=Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics 8 �fl15 <br />����►V� <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. HEAIT <br />�EH�ir/SF}jViCEs FJ <br />1®Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT IN <br />41 <br />/q'�— <br /> <br />RACTITIONERflNtY <br />Date of Birth: _ --7 Gt <br />Gender: M or (circle one) <br />Identification Type: MDrivers License MOther <br />Identification No.: <br />Facility where Body Art pServices Will be Provided <br />Q \ <br />FacilityName: V <br />\ <br />Owner: 54-- W\ S <br />Address go <br />jt <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: D't —[ J Trainin Provided b : <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2[:]Laboratory Evidence of Immunity <br />4®3laccination Declination <br />IV. FACILITY LOCATION <br />1. BUSINESS NAME: <br />Location address: C <br />2. BUSINESS NAME: <br />additional sheets as necessary) <br />State: <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 />