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-�• • San Joaquin County 1868 East Hazelton Avenue Stockton, CA 95205 �� Environmental Health Department 7eL• (209} 4683420 .�1 ,ir Fax: (209)464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) i�Tattooing ©"Body Piercing QMechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMTT, OR NOTIFICATION FEES: Check all that apply. 1QAnnual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification 2�i' Annual Body Art Facility Permit III. APPLICANT INFORMATION: ^ NAME: AMCAA \l� U�a�c�tt� Phone• .,1��,-�3'�-^-��'��`{ ,,, IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) L. tlUb11VtS' nlAl`7C: Location address: Suite; City: State: Zip: County; Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements govern►ng safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify tit to th,,c best of my knowledge and belief the statements made herein are true and correct, Signature: Print Name: Date: Title: �y�/ FOR OFFYCE USE C1NLY Program (PE): � (ai Fees: .__.. ._ Authorized by (RENS): �,SiFt(� Date Entered: BODY ART PRACTITIONER ONLY Date of Birth: Gender: F or M (circle one) Identification Type: Drivers License Other Identification No.: Facility where Body Art Services Will be Provided Facili Name: Owner: Address: Evidence of Six -months of Related Experience Facilit Name: Owner: Address: Service You Provided: Su ervisor Name and Contact Information: Bloodborne Pathogen Traininfl: Submit Certificate Date Com leted: Trainin Provided b Hepatikis 8 Vaccination Status: Choose One and Submit Documentation laCertification of Completed Vaccination 3�Contraindicated for Medical Reasons 2QLaboratory Evidence of Immunity 4�Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) L. tlUb11VtS' nlAl`7C: Location address: Suite; City: State: Zip: County; Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements govern►ng safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify tit to th,,c best of my knowledge and belief the statements made herein are true and correct, Signature: Print Name: Date: Title: �y�/ FOR OFFYCE USE C1NLY Program (PE): � (ai Fees: .__.. ._ Authorized by (RENS): �,SiFt(� Date Entered: