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0 San Joaquin County 0 1868 East Hazelton Avenue Environmental Health Department StocktonCA , p Tel: (249)) 468-3420 e Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURAS TO BE PERFORMED: Check all that apply (see back for definitions) [:Xrattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIR REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1 Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit E: +- IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: Date of Birth: '� Gender: Mor M (circle one) Identification Type:rivers License MOther Identification No.: County: Owner/ Contact: Phone/ Fax: Facility where Body Art Services Will be Prov d d FacilityName: �i Owner: `1 w�l Address t (— State: Zip: County: Owner/ Contact: Phone/ Fax: Evidence of Six -months of Related Experience Facili Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate /; Date Completed: Z"IqTrainlng Provided by: l Hepatitis B Vaccination Status: Choose One and Submit Documentation laCertiflcation of Completed Vaccination 3MContraindtcated for Medical Reasons 2EJLaboratory Evidence of Immunity 4 acclnation Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governin safe body a practices or practices governing mechanical stud and clasp ear piercing. I hereby certi t e bes powledge and belief the statements made her 'n ar true and correct. l Signature: � Date: Print Name: t9 C Title: