Laserfiche WebLink
r <br /> San Joaquin County 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton)(209))468-3420 <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 /> attooing 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 FO ATION: f� JJ�� }� (� <br /> NAME: 2 <br /> V 1 Phone: l?b t s7 <br /> HOME ADDRESS: Email: <br /> Cit State: Zi County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: I() Gender: F or M (circle one) <br /> Identification Type: MDrivers License Other Identification No.: P —f-C, <br /> Facility where Body Art Services Will rovided <br /> Facility Name: ! Owner. <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com feted: 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):( tt ch additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: I WAq' Suite: <br /> B tton <br /> Cit F State: Zi Count nA10 <br /> Owner/Contact: bffwlw ufTwPhone/ 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 otification and agrees to operate in accordance with all applicable state and local <br /> requirements gover g safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t o the bf y knowledge and belief the statements In qle herein are true and correct. <br /> Signature: Date: <br /> Print Name: VIOM Title: i2 <br /> FOR OFFICE USE ONLY <br /> Program (PE) ` Fees: Authorized by(RENS):; Date Entered: <br /> If 2 <br />