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San Joaquin County 1868 East Hazelton Avenue <br />05 <br />Environmental Health Department Tel: (209))StocktoncA 468--34203420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCED ES TO BE PERFORMED: Check all that apply (see back for definitions) <br />OTattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding OPermanent cosmetics <br />II. REQUIR6 REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />BODV ART PRACTITIONER ONLY <br />Date of Birth: loQ <br />Gender: M or M (circle one) <br />Identification Type: Drivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: �(207 <br />Owner: <br />Address: <br />152 <br />S2v2 <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: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: I I IS 202 Training Provided <br />by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r'lCertification of Completed Vaccination 3r7Contraindicated for Medical Reasons <br />2[.:]Laboratory Evidence of Immunity 4uVaccination Declination <br />IV. FACILITY LOCATION (S); (Attach additional sheets as necessary) <br />Suite: <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 of my knowledge and belief the statements made herein are true and correct. <br />Signature: - Date: IZZ J <br />Print Name: yL` Y jLj'� �l�i. Title: o 1) Or <br />OFFICE USE ONLY <br />I 11 <br />3m (PE): IIa Fees: ISL Authorized by (RENS): Date Entered: <br />