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` ¢ "'�s San Joaquin County 1868 East Hazelton Avenue <br /> ' <br /> Environmental Health DepartmenStockton,CA 95205 <br /> t 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) <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ib�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: K-') . \.� 1 1 T Phone:CZ ` 'Cl)3 <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: (> vu, c� -7 Gender: F or MM (circle one) <br /> Identification Type: r7fDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1 1 i� � Owner: <br /> Address: \ -ST C P c I'sL 4')- <br /> Evidence <br /> 2Evidence 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: 1 C 1 Training Provided by: a;r2T <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1EDCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4[Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <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 off my knowledge and belief the statements <br /> /made herein are true and correct. <br /> Signature: � 7/��i''_ •� Date: <br /> Print Name: Title: T— <br /> FOR OFFICE USE ONLY <br /> Program(PE): tilto Fees: (}� Authorized by(REHS): A t <br /> _ r f2 <br />