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C <br />San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />i 1 Environmental Health Department 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. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />®Branding ®Permanent Cosmetics <br />II. REQUI D REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 01 <br />iLy jAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: c� <br />NAME: H� ` VJ Phone: E t J <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: t Oil Gender: F or MM (circle one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facili Name: SM M06A Owner: <br />Address: 7.5 U i 0.S#- 5} CA oksl-f-C <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided b E 1 <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certiflcation of Completed Vaccination 3=lContraindicated for Medical Reasons <br />2®Laboratory Evidence of Immunity 4 PqVaccination 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 her t of mv kn dge and belief the statements mad herel!'n are true and correct. <br />Signature: Date: i 17 1 ( J <br />Print Name: Title: Z/f/.? �5 c <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (REHS) Date Entered: <br />r <br />