Laserfiche WebLink
San Joa�uim �u� �� ������� <br /> -- Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> ~n�~ <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO as PERFORMED:Check all that apply (see back for definitions) <br /> 12j Tattooing [:DDodyPiercing [::]Mechanical Stud and Clasp Ear Piercing <br /> ElBranding =Permanent Cosmetics <br /> II. mEQuz ED mEmzsTmArzOm, PERMIT, OR woTzFICArzVn FEES:Check all that apply. <br /> zAnnual Body Art Practitioner Registration 3=Mechan|ca| 3tud and Clasp Ear Piercing Notification <br /> z=Annua| Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> City: State: zip: <br /> BODY ART PRACTITIONER ONLY <br /> bate of Birth: 1wil k Gender: ED or r/140% (circle one) <br /> Identification Type: r—,>Ibrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> 45idence of Six-months of Related Experience <br /> Facility Name: Owner: <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=Contra indicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4=vaccination Declination <br /> IV. FACILITY LOCATION (s):(Attach additional sheets os necessary) <br /> 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 tooperate in accordance with all applicable state and local <br /> requirements governing safe body practices governing mechanical stud and clasp ear piercing. <br /> zhereby certify thatthe statements m <br /> Signature: <br /> Date: <br /> Print Name: nue: <br /> FOR OFFICE 1jSE ONLY <br /> Program (PE): Fees: Authorized by(REHS): te Entered: <br /> If2 <br />