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a San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department 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) <br /> Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1�3Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFOR TIO�N: f �t 1 <br /> NAME: I Id/ L <br /> Cr �1 / Phone: (_t 1 1�""1�2 7,,C <br /> HOME ADDRESS: '51Email: <br /> Ci State: ZiY137—OC7County: V1 <br /> Date of Birth: , '?j LA Gender: F or M (circle one) <br /> Identification Type: [232rivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: Owner: Anul <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <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 .51 lContrainclicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity ioVaccination Declination <br /> IV.FACILITY LOCATION (S •(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: \ <br /> Location address: Suite: <br /> Ci State: Zi Count cit <br /> Owner Contact: 2 CIL 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 governing mechanical stud and clasp ear piercing. <br /> I hereby certify th t to the be t of my k owledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: e, A Title: <br /> Tr <br /> f2 <br />