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0 San Joaquin County <br />Environmental Health Department <br />• 1868 East Hazelton Avenue <br />Stockton, CA 95205 <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) HtutiVELS <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics JUL 2 Z��2 <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ENVIRONMENTAL HEALTH <br />itiAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing RO MMSERVICES <br />2[DAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: / <br />NAME: /�„s��/l'/Phone <br />City <�z/l/„�L/moi/� State: /�� Zip: ��'%i/I] County: <br />,€t_., . ,t,`BODY`ART PRACTITIONERONLY <br />Date of Birth: n �i2 Gender: M or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />FacilityName: e1W4 ) Owner: <br />Address: _ C <br />Evidence of Six -months of Related Experience <br />Facilit Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: ' / Z- Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[DLaboratory Evidence of Immunity 4aVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <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 governing mechanical stud and clasp ear piercing. <br />I hereby certify that to thg bye t f my knowledge and belief the statements made herein are true and correct. <br />Signature: !� Date: %— 0 Z_ <br />Print Name: � t K LJ L ] Title: Th) <br />FOR OFFICE USE ONLY Date Entered: <br />Program (PE): Fees: Authorized by (RENS): <br />