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' San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> ironmental Health Department Tel: (209)46Stockton,468--34203420 <br /> ,N Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDU TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRE EGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[:3Annual Body Art Facility Permit <br /> III.APPLICANT IN ORMATION: <br /> NAME: ILL= Phone: . (o2--3-e&&6;7 <br /> HOME ADDRESS: Email: G W �✓h <br /> city: State: Zi (a Count b 1 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gend�ner: F o M circle one) <br /> Identification Type: - Drivers License Other Identification No.: 4 <br /> Facility where Body Art Servics Will be Provided <br /> Facili Name: Owner: c/1 <br /> Address: <br /> Evidence of SiT <br /> ont of Re ted Exp de <br /> FacilityName: � .F6 Owner: <br /> Address: <br /> Service You Provided: p <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 /> 1MCertification of Completed Vaccination3 Contraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity Vaccination Declination <br /> IV. FACILITY LOCATION :(Attach Idditional sheets as necessary <br /> 1. BUSINESS NAME: <br /> Location a dress: Suite: <br /> City: 1A State: Zi ount : <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 N ification and agrees operate in accordance with all applicable state and local <br /> requirements gover i g afe bo y art pract' s or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t t edge and belief the statements made herein are tr a and correct. <br /> Signature: Date: ===1ZL <br /> Print Name: Title: <br /> I-171S t <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> f2 <br />