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San 3oaquin CoLInt:1� 5868 East Hazelton Avenue <br />Stockton, CA 95205 <br />imnui9`e6i6`u`#ental H eaftiirl DePai-tract"It TEI: (209) 463-3420 <br />Fax: (209) 464-0138 <br />BODY AR71 FAC' LITI Y AND PRACTITIONER REGISTRATION/ <br />EAECHAMICAL STUD AND CLASP EAR PIERCING MOTIFIOIATZOM <br />a. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Iattoo[ng Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />XL REQUIRED nrm-�.eST RATKON, PERMIT, OR NOT7 <br />F®cAa 10ff<9 FEES: Check all that apply. <br />i Annual Body Ari: Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2®Annual Body Art Facility Permit <br />III. APPLICAJ4T XMIFOREaATZON, <br />_. _ ..p_ Phone: <br />��®V Ai�-ri f�l�AC�'I�'I®Era �ivl�V <br />or R1 (circle one) <br />Date of Birth: —0 Gender: <br />Identification Type: MDrivers License Other Identification No.: <br />FacilitV vrhere SodV Art Services Will he Provided <br />e <br />Facility NOwner: -Vila <br />Address: ✓ <br />Evidence of Six -months of Related Ex[. evience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certiflcate � > �� <br />Date Completed: 1 TrainingProvided by: e <br />ro <br />Hepatitis B Vaccination Status: Choose One and Subrnit Docuuo� emanon <br />1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4 Vaccination Declination <br />W. FACILI`b"Y LOCATION (S): (Attach additional sheets as necessary) <br />:t. BUSINESS MAME: W. —'Vi <br />Location address: 33 k v <br />ZID: <br />Owner/Contact:'a /^AAAAAl k \ Phone/ Fax: (GV4l/ is --7 4--`1y'9l/ <br />2. BUSINESS MAME: <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 car piercing. <br />a 6�erc-C3 f cep°e i%} ehac t© 6 e j <br />o'n rEb I UrP— Ulcc ce and G rief the sta'�arnentc M. ae'se here -in are tree aeEi correete <br />Signature: -- Date: ® --- <br />Print Name: Ti'i(e: - <br />l;°Gft aFFICH USE OULY <br />Program (PE): Fees: Authorized by (REI S): Date Entered: <br />-- <br />e <br />VF vt <br />