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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department <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. PROLE ORES TO BE PERFORMS :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 /> 1Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT I RMATION• <br /> <br /> <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: - 1 Gender: F'I o M (circle one) <br /> Identification Type: Drivers License Other Identification No': <br /> Facility where Body 11 <br /> rt Services Will be Provided <br /> Facilit Name: O Owner: <br /> Address: , <br /> Evidence of Six-months of Related Experience <br /> t ' � <br /> Facility Name: �' Owner: <br /> Address: <br /> Service You Provided: ! <br /> Supervisor Name and Contact Inform m ®� <br /> Bloodborne Patho�ttge tif <br /> Trai ing: Submit Cericate <br /> ! <br /> Date Completed: Training Provided by: <br /> Hepatiti B Vacci atio Status: Choose One and Submit Documentatio <br /> 1 Certification of Completed Vaccination 3 Contraindicated 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 /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/ Contact: 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 practic or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify tha o est of my k dge and belief the statements made herein are true and correct. <br /> Signature: Date: / <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> f2 <br />