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® San Joaquin County 1868 East Hazelton Avenue <br />Environmdnta� 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. PROCEDURES TO BE PERFORMED: heck all that apply (see back for definitions) <br />Tattooing Body Piercing Omechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: c �1 <br />NAME: - Ls Phone: ` t <br /> <br /> <br /> <br />Date of Birth: 09 I `2 <br />Gender: F or <br />M (circle one) <br />Identification Type: WDrivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />FacilityName: 0) <br />Owner: M1}- <br />\r <br />1 <br />Address: 2 i(} <br />C <br />Evidence of Six -months of Related 44Expperience <br />Facility Name: <br />Owner: <br />71 <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed 1 -12 Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification of Completed Vaccination 3 C traindicated 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 />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 that to the best ofy knowledge and belief the statements made herein are true and correct. <br />Signature: _ - _�_ Date: % f 2 <br />Print Name: s Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />a <br />