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f <br />San 3oaquin 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />r'WTattooing 1:3 Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1�Annual Body Art Practitioner Registration 3aMechanical Stud and Clasp Ear Piercing Notification <br />21—__]Annual Body Art Facility Permit <br />IIx. APPLICANT INFORMATION: <br />BODY ART PRACTITIONER ONLY <br />Date of Birth:? Gender: M or (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services <br />till be Provided <br />Facility Name:T mawcaner: <br />Address <br />Evidence of Six -months of Related Experience /► <br />Facility Name: Owner: G.0 <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen 14PT aiming: Submit Certificate <br />Date Complete Training Provided by: lam <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2QLaboratory 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 />Contact: <br />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 pcacticewpractices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to a and belief the statements ad herein are true and correct. <br />Signature: Date: 4441 <br />Print Name: W1 Title: 44S.1 - <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: _/ Authorized by'(REHS): Date Entered: <br />K�v 14111 f Ill! <br />