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San 3oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department S t05 <br /> o CA 952 <br /> 2o9) 20 <br /> rY ...w Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDYRES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> 12ITattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[ffAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICA T INFORMATION: <br /> NAME: (� Phone: <br /> <br /> <br /> OW, W.R <br /> Date of Birth: Gender: M or MM (circle one) <br /> Identification Type: MDrivers License M10ther Identification No.: <br /> Facility where Body Art Servic s Will a Pr 'ded / <br /> Facility Name: Owner: / <br /> Address: <br /> Evidence of Six-months of Related Zerience <br /> Facility Name: Cly �(� Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: 5 Training Provided b L?( <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[Dvaccination 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: <br /> Print Name: Title: <br /> 3 <br /> f2 <br />