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h. San Joaquin County 1868 East Hazelton Avenue <br /> 4knvironmental Health Department* Tel: (209))4468--34203420 <br /> StocktonCA 95205) <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 /> i�Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2[:3Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: ^ `S Phone: 20S <br /> HOME ADDRESS: Email: 0dF <br /> Cit : State: CA _Zi .. County: i <br /> Date of Birth: ^'C) Gender: F or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: Owner: <br /> Address: <br /> 4 <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: 2.125 12026 Training Provided by: c <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[M Certification of Completed Vaccination 3[-7Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 1 <br /> Location address: .-, 4— i J <br /> Unit Suite: <br /> City• inn State: ( r T Zip: GIC)2 ISI County: 1(�Y� <br /> Owner/ Contact: B m ��'o Phone/ Fax: ��� �I� 9401 <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 9f my knowledge and belief the statements made herein are true and correct. <br /> Signature: C - w �� h Date: " ZIC <br /> Print Name: (��(' L>{�j 1 (,7� Title: <br /> nev f2 <br />