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San Joaquin County 0 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <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 />PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />DKITattooing EDBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />M� 1015 <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. P —r—MME,HE <br />1�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notifica'96W4Vzeii% <br />2[DAnnual Body Art Facility Permit S <br />III. APPLICANT INFORMATION: <br />R <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />v <br />Date of Birth: •- 2 rj - (�g% <br />Gender: <br /> <br /> <br />Facility where Body Art Ser�v/iices Will be Provided <br />Facility Name: 164Le <br />Owner: <br />Address: 27k, 6_n2- fZ aAc <br />Evidence of Six -months of Related Experience <br />Facility Name: •i1 �1-Z� M <br />///i� Owner: p/ <br />Address: �+ <br />y <br />Service You Provided: I f <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: R 1wr Training Provided <br />L <br />b Ve <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity <br />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 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 />Signature: f!' k jj Date: <br />Print Name: Title: <br />r IT <br />49T."#},mF k. N?Fy. � � Y� $ • �' �' � � " � � lei MIS mk� � "�'�s � • '� �4 t�-in4.� du. � rv� <br />