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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />p 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 />Tattooing r7Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />/ /1 .'1 *'Cr- Phone: �- c 7 ( iv 5 C C <br />Date of Birth: 0. o / 7 -:�- Gender: M o M(circle one) <br />s <br />Identification Type: Drivers License Other Identification No.: � -7 l '7c7 <br />Facility where Body <br />ff IArt Services Will bee Provided $/ ry7J' 7 <br />Facilit Name: L1 N V�/ A/ / 1 7 O O Owner: � l / � <br />Address: Z�` 6t �,/ 7� ,e S' -+t A C C 2 c `' <br />Evidence of Six -months of Related Experience <br />Facility Name: �Ski� / 7"?0�� Owner: <br />Address: 2� 1 �' G "T 7.7 js ` <br />Service You Provided: <br />Supervisor Name and Contact Information: i Z <br />Bloodborne Pathogen TTraii ing: Submit Certificate <br />Date Completed: `�G/ /1 � L Training Provided by: l -/t`T _ A -f <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1,®Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets <br />iINESS NAME: x <br />necessary) <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: 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 th tote t of owledge and belief the statements m de herein are true and correct. <br />Signature: -� `"' Date: <br />Print Name: ltlC l-eTitle: 1-4 T <br />F/4 00 01'21 QO? <br />2 <br />