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°� • San Joaquin County • 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 9S205 <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 />QTattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding r7Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1�Annual Body Art Practitioner Registration 3MMechani4'5tud and Clasp Ear Piercing Notification <br />nual Body Art Facility Permit <br />III. APPLICANT INFORMATIO <br />n <br />51 <br />HOME ADDRESS: 2 <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: Q ` 9 7% <br />Gender: F or M (circle one) <br />Identification Type: Drivers License MOther <br />Identification No.: 2� <br />Facility where Body Art Services Will be Provided <br />Inn <br />FacilityName: ' V <br />/�^ <br />aer: aK `'pPv' y \/ <br />Address: N <br />VI C31 0 -L <br />Evidence of Six -months of Related Experience <br />Facility Name:^Owner: <br />'V 1 <br />Address: 1 <br />Service You Provided: <br />State: <br />Supervisor Name and Contact Informatio <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit <br />Documentation <br />1MCertification of Completed Vaccination <br />3r--IContraindicated for Medical Reasons <br />2[=]Laboratory Evidence of Immunity <br />4[Zlvaccination Declination <br />iI cow <br />IV. FACILITY LOCATION ( <br />: (AttachhaOditional sheets as ece .5=) <br />SICK �I i at -f Do <br />�_)-m did <br />1. BUSINESS NAME: <br />V/ 1 <br />Location address: <br />Suite: <br />City: <br />State: <br />Zi <br />O <br />County: <br />eOWner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />Cid: <br />State: <br />Zip: <br />County: <br />Owner/ Contact: <br />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 t to the_best of my knowledge and belief the statements made herein are true and correct. <br />�h` 'A1r- -13 <br />Signature: Date: <br />Print Name: Title: V V eir— <br />FOR <br />OFFICE U, <br />Program (Pt):� Fees Authorized by_(REHS)r Date Entered: ��. . <br />syr <br />