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'San 3oaquin County 10 1868 East Hazelton Avenue Stockton, CA 95205 Environmental Health Department Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. it: rAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit III. APPLICANT IN IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements Bo ning saf be y art practice r practices governing mechanical stud and clasp ear piercing. I hereby certify atAo th t oVlr y kno gdge and belief the statements made herein are true and correct. Signature: ,t/JG�/�Date: 10 --31 — 1`3 Print Name: / / L JAA VI 7c1/1 /GTitle: 7-0 rh60 14)-4-1 Sfi Date of Birth: — © _ Gender: M o —M1,Wcircle one) Identification Type: Drivers License Mother Identification No.: % Facility whereBody Art Services Will be Provided FacilityName: Owner: O ylt'�a Address: L Evidence of Six- onths of Related Ex erience facilityName: Owner: Address: Service You Provided: Name and Contact Information: 1 -7 L53 .Supervisor Bloodborne Pathogen Training: Submit Certificate Date Completed: 2% — 7,Gl/ 3 Training Provided b , Hepatitis B Vaccination Status: Choose One and Submit Documentation 1[:]Certification of Completed Vaccination 3[DContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4 accination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements Bo ning saf be y art practice r practices governing mechanical stud and clasp ear piercing. I hereby certify atAo th t oVlr y kno gdge and belief the statements made herein are true and correct. Signature: ,t/JG�/�Date: 10 --31 — 1`3 Print Name: / / L JAA VI 7c1/1 /GTitle: 7-0 rh60 14)-4-1 Sfi