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San Joaquin County 0 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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. PROCEYURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> nTattoolng ®Body Piercing [::]Mechanical Stud and Clasp Ear Piercing <br /> ®Branding [:]Permanent Cosmetics <br /> 11. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[::]Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> 1-11, <br /> 111.APPLICANT INFORMATION: <br /> NAME: J00-.- Cr Phone: 80en, <br /> HOME ADDRESS: ua%3 LAG., Vtj. -SJ cA,, Email: <br /> City: State: Zip: County: <br /> Date of Birth: A 0-5-da.- Gender: F or (circle one) <br /> Identification Type: LDDrivers License Vother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: QTCnW'- C.j44M 401=20�� Owner: <br /> Address: k3j :Jk. eCA).�fc,, c�A S-2iA 1 rA, <br /> Evidence of Six-months of Related Experience <br /> Faci I&Name:-M ) Owner: <br /> Address: . C"0- V--� --S%j <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: jhZXj= --A-o Training Provided by: jP!EQ C21["�n4 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1E2,Certlflcation of Completed Vaccination 3 MContraindicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4_Vjaccination Declination <br /> L <br /> IV.FACILITY LOCATION (S).(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: "Ou <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 goveming mechanical stud and clasp ear piercing. <br /> I hereby certify that to the est of my knowledge and belief the statements made herein are true d correct. <br /> Signature: Date: )(Jig d <br /> Print Name: Title: <br />