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San Joaquin County 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />Annual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMA' <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: iJ�j t{ Gender: or M (circle one) <br />Identification Type: rs License MOther Identification No.: <br />Facility where Body Art Services Will be Provided ` %q <br />FacilityName: '� Z ✓�0Owner: t & - 7 -- <br />Address: <br />Address: 'L ` (A <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 />1MCertification of Completed Vaccination 3[--IContraindicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity 4=Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />State: Zi <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />Suite: <br />Cou <br />Location address: Suite: <br />State: Zio: <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 t�ibest of my knowledge and belief the statements n <br />Signature: C/Yl.�"-��i�� Date: <br />Print Name: e 7CIS cc\>--r� (l0 —r-0 Title: Q <br />are true and correct. <br />FOR OFFICE USE ONLY <br />Program (PE):Fees: Authorized by (RENS): 2 ► Date Entered: <br />