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San Joaquin County 1868 East Hazelton Avenue CA Environmental Health Department Stockton, 4 46 -3220 P Tel: (209) 68-3420 # Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) FESITattoolng Body Piercing MMechanical Stud and Clasp Ear Piercing OBranding 1:3 Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. iM[Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit III. APPLICA�11T INFORMATION: NAME: , Mot--) t--) F5T-P—A r1i'X Phone: S i A —7 Z--? 'I -- . IV. FACILITY LOCATION (S)t (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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that a st o know belief the statements made herein are true and correct. Signature: Date: Print Name: e Title: FOR OFFICEaUSE ONLY ti '` 5 Pr`ograjr((PE) Fees , as Authonzei! by (REHS) Date Entered ' Date of Birth: Gender: F or M (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: Owner: Address:3i /,r Evidence of Six -months of Related Expe�ri/�nce % FacilityName: 1 a S /V �— Owner: �/g/v Address: Service You Provided:Supervisor Name and Contact Information: CA Af AA—WL—E 5 Bloodborne Pathogen Training: Submit Certificate Date Completed: - 2e?- Zo( Training Provided b 4 cA/7—Atf Hepatitis B Vaccination Status: Choose One and Submit Documentation�� lertification of Completed Vaccination 3MContraindicated for Medical Reasons 2 Laboratory Evidence of Immunity 4[DVaccination Declination IV. FACILITY LOCATION (S)t (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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that a st o know belief the statements made herein are true and correct. Signature: Date: Print Name: e Title: FOR OFFICEaUSE ONLY ti '` 5 Pr`ograjr((PE) Fees , as Authonzei! by (REHS) Date Entered '