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,a 27 2 j San Joaquin County 1868 East Hazelton Avenue <br /> Stckton,CA Environmental Health Department T l0 209)468-3420 <br /> 9HEAL <br /> 5205 <br /> Environmental <br /> E Fax: (209)464-0138 <br /> E IT/SE1 ODY 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 Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: tr � <br /> NAME: 1 �i Q r Phone:�� ®®��® <br /> HOME ADDRESS: ! ,rd o Email J`71S C k A00 <br /> Cit 1 1 ` 5 Zi : Z Coun <br /> OrlBODY ART PRACTITIONER ONLY <br /> Date of Birth: �' Gender: F or M (circle one) <br /> Identification Type: Drivers License Mother Identification No.: <br /> Facility where Ekody Art Services Will be Provided , <br /> FacilityName. 11 Cq �r Owner: W 'A <br /> Address , TI\i , Q <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;7 16 Training Provided by: (,,Cry K2,8 ,to I <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address:' Suite: <br /> Ci : State: e zi County: 'I ✓) <br /> Owner Contact: A e i/I hone Fax: 7,0C - ' <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 my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: l Authorized by(REHS): Ci to Entered: <br /> If2 <br />