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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department el: (209)on, 46 -3220 <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 1, 3 <br />1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) —�-OM1%f <br />attooing Body Piercing Mechanical Stud and Clasp Ear Piercing DEC 1 �Z <br />Branding OPermanent Cosmetics `5 21016 <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. PERMIT% R HEALTH <br />i�Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification 1//CE. <br />2QAnnual Body Art Facility Permit <br />II: <br />BODY ART PRACTITIONER ONLY <br />Date of Birth:}' Z Gender: M or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: L i {i " 1 Owner. U <br />Address: 1 l <br />Evidence of Six -months of Related Experience <br />Facili Name: v "' C Owner: Z:�>C41j` <br />Address: iL- `� 1- 13 <br />Service You Provided: <br />Supervisor Name and Contact Information: Z6-,✓(. L2�-,"1,- S� <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />l ertification of Completed Vaccination 3�Contra(ndlcated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[DVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: ` "•-)I� [� `� �L � ✓tom Avg /( Suite: <br />city: Vv.i i/N4-eCCA State: L A Zio: q; ��� h County: SO" <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 1:14est nowledge and belief the statements made herein are true and correct. <br />Signature: `!%/jf- Date: �� ) <br />Print Name: VV& � Title:. <br />FOR OFFICE USE ONLY - <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />(�) <br />