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San ]oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> FAtCEIVED <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATIONe <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) 6 2014 <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MA ual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATI N <br /> NAME: Phone: <br /> <br /> <br /> .� a. <br /> Date of Birth: — Gender: F or M (circle one) <br /> Identification Type: r7jlDrivers License Mother Identification No.: / <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: / Owner: <br /> Address: 6J. i _ <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 Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[::]Contraindicated for Medical Reasons <br /> 2MLaboratory 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 to the best m knowledge and belief the statements made herein a e true and correct. <br /> Signature: ✓i� Dater ^ �� �� <br /> Print Name: Title: <br /> ... <br /> PrQ � �� $ 8 1tOfZe x sI)atE Enfered <br /> f2 <br /> I <br />