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San ]oaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> ! Environmental Health Department Tei: (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. P'ROCEDYRIfS TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIR REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATI0 : ` -) <br /> NAME: l 1 1 I'V') cCCsr,, Phone:� —z 1 i L4 !, <br /> <br /> <br /> <br /> <br /> AR;1IPRACTITIOINER Isa <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provi ed <br /> Facility Name: Owner: <br /> Address: 3c • �_ - V\_ <br /> Evidence of Six-months of Related Experience <br /> Facility Name: V- Owner: <br /> Address: <br /> Service You Provided: Vk c-,-0 <br /> Supervisor Name and Contact Information: <br /> Bldodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertificatlon of Completed Vaccination 3MContralndicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4Mvaccination 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'thate;b azt of my k ledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> 3�Enn W,e`.'d <br /> _�HoR.OFCr n <br /> " re <br /> m. -,+w tv t•.. e.. <br /> f2 <br />