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` San Joaquin County 1868 East Hazelton Avenue <br /> =. <br /> CA <br /> Environmental Health Department Stockton,460 <br /> P Tel:(209)468--3423420 <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 /> Branding Opermanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> it2fAwrinual Body Art Practitioner Registration s Mechanical Stud and Clasp Ear Piercing Notification <br /> z Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Phone: <br /> 56 <br /> HOME ADDRESS: Email: Go001-S, ! <br /> city: State: - Zip: Z to County: [e <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: ) Gender: EF or M (circle one) <br /> Identification Type: vers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: ' I Owner: ✓`'� <br /> Address: i° ` u <br /> Evidence of Six-months of Related Experience <br /> Facility Name:aoudiq akaj-Toc? Owner: <br /> Address: �— C, - CAA ot ' 1 <br /> Service You Provided: TOO r <br /> Supervisor Name and Contact Information: n 1 1''3 <br /> BloodborneP t Trainin Submit Certificate <br /> I L ' ® -r <br /> Date Completed 1 Training Provided by: ` 1 r.�l i I <br /> `Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certiflcatlon of Completed Vaccination 3Contraindicated for Medical Reasons <br /> 2(--ILaboratory Evidence of Immunity 4 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�bo art practic or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to of my kn e d belief the statements niade her in are true and correct. <br /> Signature: Date: Ito <br /> Print Name: Title: 'rte <br /> FOR OFFICE USE ONLY <br /> Program(PE): 1 Fees: P Authorized by(REHS)s Date Entered: <br /> f2 <br />