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A 95205 <br /> • Tel: (209))4468--34203420 <br /> San Joaquin 6unty 1868 East Hazelton Avenue <br /> �a Environmental Health Department Stockton <br /> 6 <br /> 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 MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Elermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 12]'Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: �ti�/�L /arL/�c�t(f. Phone: Pc-':1) YZJ` 60ceI <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: /Cf /elcq Gender: M or (circle one) <br /> Identification Type: ` Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: f-:/' V ye'v 11 c CE Owner: ? <br /> Address: 1.✓ j i e' re.1SA— <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: Zc l Training Provided b /'�✓ �'C'6 c>' -%tom <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: ; "�/''";�' Date: G' ,lc?rc`1 <br /> Print Name: J`Stvl, fp, n degv'�E/ Title: _x/14 b'5f <br /> FOR OFFICE USE ONLY <br /> Program (PE): MD— Fees: ��j2�� Authorized by (RENS): ate Entered: <br /> if 2 <br />