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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (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 /> Tattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> i ®Branding ermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> III.APPLICT INFORMATI® <br /> NAME: Phone: 111- 1 <br /> HOME ADDRESS: l/ Crt ve Email: r . <br /> Ci State: Zi Count <br /> BOD_ ,ARTA? ACTITIONER.ON <br /> Date of Birth: Gender:J�rFj or MM (circle one) <br /> Identification Type: nDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: Y Owner' <br /> Address :9 Q LoL 0 CtL <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 b C i <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3[DContraIndicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity accination 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 cert!fVtAatto the of my knowle a and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: f s- <br /> FO OFFIGE''US <br /> o E), a s ut o ze y(RENS)'.. Date:..: tEre <br /> Q <br />