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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> ;> Tel: (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 /> Tattooing ody Piercing EDMechanical 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 IN RMATION: <br /> NAME: Phone: <br /> HOME ADDR SS: 117 N Email:I"A " <br /> Cit State: Zi Countv: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: 74 100 <br /> Facility where Body Art ervic s Will be Provid d®®�� <br /> FacilityName: " aV Owner: <br /> Address: 7- <br /> Evidence of Six-months of RellateY Experienc <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <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 tha It best of m k yJe e. belief the statements made hereq&areArue and correct. <br /> Signature: Date: dVA1*j, 0-011101 <br /> Print Name: Title: :IU114 ;)Lola <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: 990Authorized by (RENS): L& Date Entered: <br /> rKev 12711 1, f2 <br />