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San 3oaquin County 1859 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tei:(209)469-3420 <br /> Fax:(209)464-6138 <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 M anicai Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATIO Owl/ <br /> Phone: 6 U <br /> HOME ADDRESS: Email, <br /> Citv: State: Z101. County: <br /> Date of Birth: / �r®C '� Gender: M or MM (circle one) <br /> Identification Type. MDrivers Ucense Other Identification Pio.: p <br /> Facility where Body Art Se ice:will be Provided }� <br /> Facilltv Na Owner: / <br /> A <br /> ILL Q � <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> rvl e y u Provided: <br /> Su22rv1sor Name and Contact Information: <br /> Bloodborne Pathogen Training:Sub t Certificate <br /> P <br /> to Com leted: !�f Tr in[n P ;vi ed b : <br /> Hepatitis-B VaccinationStatus:Choose One and Submit Documentation <br /> 1[Z]Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of immunity acdnation Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> pity: State; Zip: County; <br /> Qwner/Contact' Phdnel Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City: SWI: Zip; County: <br /> 4wnerl 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 Notiflcation 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 that the best of my ka wied a and bellef the statements made herein are true and correct. <br /> Signature: Date: <br /> _ f` f <br /> Print Name: Title: <br /> 2 <br />