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San 3oaguin County 1868 East Hazelton Avenue <br /> t nvironmental Health ar <br /> De tmen Stockton,CA 95205 <br /> P 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 Zmanent <br /> Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Cosmetics <br /> II. REQUIRE EGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION, <br /> NAME: /� V Phon : <br /> HOME D ESS: l�r Email: ' <br /> Ci a State: Zi : County: <br /> • <br /> Date of Birth: Gender:41M o M (circle one) <br /> Identification Type: rivers License Other Identification No.: <br /> Facility where Art Services Will be Prov!46—d) <br /> —7 <br /> FacilityName: Owner: <br /> Address-2 <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 /> i®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 accination Declination <br /> IV. FACILITY LOCATIO :(Attach additiopail sheets as nec ry) <br /> 1. BUSINESS NAME: <br /> Location address 9M4t� - Suite: <br /> city L State: Zi r CWCoun <br /> Owner Contact: 2 7 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 ce ify that t s o myowledge and belief the statements made erei are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> f2 <br />