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San Joaquin County 1868 East Hazelton Avenue <br />Sto95205 <br />Environmental Health Department el: (209)kton, 46 -3420 <br />4 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 />',gTattooing aBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding QPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />iii. APPLICANT 3 <br />INFORMATION: z <br />NAME JI(a 4, 1At' <br /> <br /> <br />IV <br />BO �ART7PRACTITIONERCi'NLX.+�'`'' <br />Date of Birth: Gender: F or M (circle one) <br />Identification Type: MDrivers License ther Identification No.: <br />Facility where Body Art Services Will be PrlCvlded <br />Facili Name: — Owner: <br />Address –i <br />,� 3 <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: fig' <br />Supervisor Name and Contact Information: i 1 <br />Bloodborne Pathogen Training: Submit Certificate <br />� r <br />Date Completed: Trainina Provided by: '� �✓?���. <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br />Laboratory Evidence of Immunity 4[:Dvaccination Declination <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 es owFeedg nd belief the statements made herein are true and correct. <br />Signature: Date: <br />Print Name: Title: <br />ON <br />� <br />