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San Joaquin Countyto CA 95205 <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Tel: (209)46Stockton,468--34203420 <br /> p <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 Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 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: ze Phone: <br /> HOME ADDRESS: Email: <br /> City: N State: Zip: Coun : 1 <br /> Rt'IE�Y AR`1''P )TONER ONL1F <br /> Date of Birth: ? Gender: EDor CE (circle one) <br /> Identification Type: ImDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: V� Owner: <br /> Address: vy'" <br /> Evidence of Six-months of Related Experience <br /> Facility Name: C4 Owner: <br /> Address: <br /> Service You Provided: p e <br /> Supervisor Name and Contact Information. i <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: o" �' l` x-' <br /> Location address: t Suite: <br /> Ci 1 � `� County: <br /> City: �i <br /> t C�C",�,.. ^ State: C- PokZip' y-.113 <br /> Owner/Contact: Phone/Fax: '7e-?7 ® � G <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 tha th est of ply knowle0o and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: r ti <br /> F()R OFFICE tiSE ONLY <br /> Program(PE): w <br /> Fe : � Authorlletf b?/�R��i ): Date,tnteredl:­ <br /> f2 <br />