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San Joaquin County 1868 East Hazelton Avenue <br />J Environmental Health Department <br />Stockton, <br /><; p 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />®Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: A_ x` 6 / <br /> <br />BODY -ART PRACTITIONER ONLY <br />1.4 <br />Date of Birth: 1 / <br />Gender: F <br />o (circle one) <br />Identification Type: =Drivers License MOther <br />Identification No.: % <br /> <br />Facility where Body Art Services Will be Provided <br />FacilityName: [ <br />Owner: <br />// <br />Address: 20-7 4L M44NJ <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: I <br />Bloodborne Pathogep Training: Submit Certificate <br />Date Completed:21 Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4 CmVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />ress: <br />Owner/ Co <br />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 gr s o operate in accordance with all applicable state and local <br />requirements governing safe bo r c)?i , s or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify thatto k edge and belief the statements made he ein are true and correct. <br />Signature: Date: <br />Print Name: Title: t <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />Milo f2 <br />