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0 <br />San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />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 />1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />iWAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />II: <br />�: ",��� BODYART�PRACTITIONER,ONLY.z <br />Date of Birth: Gender: or M (circle one) <br />Identification Type: rivers License Mother Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: }c r 'cquc4 i i�& Owner:'ITIGMCASSherA <br />Address: 19 W N il IS-+ - CI <br />Evidence of Six -months of Related Experience <br />Facility Name: \A o6 r 1 Owner. ` C.Ma `Sl' 0 <br />Address: G <br />Service You Provided: <br />Supervisor Name and Contact Information: ' i <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 10 a-2 I I q Training Provided by: b, i X. Sol Lt -h on's <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[DLaboratory Evidence of Immunity 19 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:Date: to <br />Print Name: tu(�cyzn&e ryx n Title: <br />REHS) <br />( � ,� t <br />Progra (P� Fees Y <br />��rAuthonzed b" � Date Entered � tt�, , <br /> <br />