Laserfiche WebLink
s 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 /> I. PROCED ES TO BE PERFORMED: heck all that apply (see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding oPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES;Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT I FORMATION: <br /> NAME: Phone: 53 33S i9qb <br /> <br /> <br /> BODY ART PRACTITIONER ONLY e- <br /> Date of Birth: Gender: F Nr r M (circle one) <br /> Identification Typ Drivers License r7Other Identification No.: <br /> Facility where Body rt Services Will be Provided <br /> Facilit Name: uct" Owner: Chin <br /> Address: 126 (Ibfll C-41 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogien Training: Submit Certificate <br /> Date Completed: <br /> Trainin Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentatio <br /> 1 Certification of Completed Vaccination 3EDSqAtfaindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 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 t f my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 11N_ <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: 15a Authorized by (RENS): Date Entered: <br /> If2 <br />