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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205Tel: (209)468-3.420 <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 /> i Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> ®BrandingPermanent Cosmetics <br /> i <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES,Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> z Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: nn <br /> NAME: Phone: "i �'_ } <br /> om <br /> HOME ADDRESS: J Email: O aLl�? � <br /> city: State: zip.. Count <br /> BOD, AR- PRAr(sT3TI0 E ;oNi <br /> Date of Birth: Gender--M—or M (circle one) <br /> Identification Type: VqDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: <br /> Al <br /> Address: L \ <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., Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2C]Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> x. 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 of my knowledge and belief the statements made herein are true and correct. <br /> Signature: 01,11 Date: <br /> Print Name: t! Title: (� <br /> FOOFF—P E�QNLees Aut o zed by(RE sj ate.E tered� <br /> Mf2 <br />