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k e•. San 3eaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />` 3 1 Environmental Health Department Tel: (209) 468-3420 <br />`= Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION &��rz <br />I. PROCEDU TO BE PERFORMED: Check ail that apply (see back for definitions) J/' —QL I F17.Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing N 2 VQ <br />Branding ®Permanent Cosmetics 4 1 t'1Vhir.» <br />2415 <br />Pe., _ <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. /sFF <br />i Annual Body Art Practitioner Registration 3[Z]Mechanical Stud and Clasp Ear Piercing Notification <br />Z Annual Body Art Facility Permit <br />III. APPLIC NT INFORMAT ON: .' I '/� <br />NAME: k I ' / lI Pli1� 1. 1 `!h <br />` BODY ART PRACTITIONER ONLY <br />Date of Birth: 0 Lf _ Gender: F or (circle one) <br />Identification Type: 2121vers License Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Owner: <br />Address: 1 <br />Evidence of Six-months <br />of Related Experience <br />Facilitv Name: 1 r `"�'0wnPr.i�i�e��0 <br />4 <br />Bloodborne Pathogep Trai Ing: Submit Certificate <br />f_ <br />Date Completed: Training Provided b <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 />Location address: Suite: <br />City: State: Zi County: <br />Owner Contact: C Phone/ Fax: �i <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 to the best of my kno g 1�td belief the statements MaAe hereigrare true and correct. <br />Signature: ! Date: (/ <br />Print Name: Title: IWV V 0 i <br />FOR OFFICE USE ONLY <br />Prograrr (PE): Fees: Authorized by;(REHS)- Date Entered: <br />f2 <br />