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San Joaquin County <br /> 1868 East Hazelton Avenue <br /> ,Y nvironmental Health Department Stockton -3220 <br /> Tel: (209))44668-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION �L:Rft <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> attooing Body Piercing Mechanical Stud and Clasp Ear Piercing JAN 08 2019 <br /> Branding =Permanent Cosmetics fE OW►y <br /> LH <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. Wr%jWjr`SERviCES TH <br /> 1 nual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> III. APPLICANT INFORM TION: <br /> NAME: .11 Phone: <br /> HOME ADDRESS: i Email: i�h %Z deeT lad <br /> City: State: Zip: Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or MM (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> FacilityName: Owner: <br /> Address: ' <br /> Service You Provided: Aniftio <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 /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 Vaccination 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 certify that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Y11 0 Fees: 152,C0 Authorized by (RENS): Date Entered: <br /> if 2 <br />