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0 <br />San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department el: (209)kton, 46 -3220 <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 />`Ta+ttooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding QPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i oAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />�`-.�TIZ: <br />Date of Birth: (J-) 2! v ` Gender: or MM (circle one) <br />Identification Type: rivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facili Name: \ T Owner: <br />CA CW)164- <br />Address: C' <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: Trainincl Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertificatlon of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[Dvaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional s <br />1. BUSINESS NAME: ­ _t" C ` ((, <br />Location address: <br />Suite: /L <br />aunty: ,�;ON" A) AG L \ ri <br />2. BUSINESS NAME: <br />Location address: ► ( Suite: <br />State: <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 the best of my knowledge and belief the statements made herein are true and correct. <br />�_V <br />Signature: ����-�— Date: <br />Print Name: �i _ \, ����� Title: <br />FOROFFICE, USE ONLY' '# `JA <br />Progra (PE) FeesWAuthonzed by (RENS) Cts..'Date EnEered <br />