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San Joaquin County 1868 East Hazelton Avenue <br /> • Environmental Health Department Stockton, CA 95205 <br /> h 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 r—loody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 121Annual Body Art Practitioner Registration 3F7Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICA T INFORM TI N: � <br /> NAME: _jyl Vf) Phon : <br /> HOME ADDRESS: Email: �ffk_ �� ' <br /> •�(,�l 1 <br /> Cit mmic(AState: ft— Zi Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: cyjI Gender. Edor MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where ody Art Service Will be Prov'ded <br /> FacilityName: rn <br /> Owner: <br /> Address: CA <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 Patho a Traini g: Su it Certificate <br /> Date Completed: Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3Meontraindicated for Medical Reasons <br /> 16— 2�Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATIONS): Ata addit nal sheets as nece ry) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> Cit State: Zi ount :,- 12 W6 1A N <br /> Owner/Contact: Phone/ Fax: A <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 t the st of 419nowledg and belief the statemen rBadp herein a tr ie and co rect. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): (1�l Q Fees: 15 S. Authorized by (RENS): 66 kh, Date Entered: <br /> If 2 <br />