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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA195205 <br /> p Tel:(209)468-3420 <br /> ow. 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 /> Tattooing aBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> � <br /> NAME: Phone I <br /> <br /> <br /> <br /> 7777777' <br /> Date of Birth: 1�4 el�r-` Gender: M or JW (circle one <br /> Identification Type: tZiDrivers License Other Identification No.: <br /> Facility where SodArt Services Will be Provided <br /> FacilityName: Owner: <br /> Address• 5 <br /> Evidence of Six-m nths of Related Experience <br /> Facility Name: ' Owner: <br /> Address: Q S• I <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> 0. E <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com feted: Training Provided by <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> y+. <br /> 1.BUSINESS NAME: r <br /> Location address: �JCU 'C- <br /> Suite: [� I <br /> Ci State: Zi County: I <br /> Owner Contact: Phone Fax• 3 3 <br /> 2.BUSINESS NAME: <br /> G <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-.rid agrees to operate in accordance with all applicable state and local ! <br /> requirements governing saf y rt practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify a of my, elief the statements made771 <br /> re true and correct. <br /> Signature: Date: 7 <br /> Print Name: Title: k <br /> FOR OFFICE USE Ol L1r' f y p <br /> Program(PE): _ �,� �� � �12�b ilt0•i��. � � ... <br /> f2 <br /> nuv 14111r- <br /> f <br />