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r San Joaquin County 1868 East Hazelton Avenue <br /> l ironmental Health De artment� <br /> Stockton,CA 3220 <br /> nv <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 /> oTattooing 0Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> aBranding oPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 123Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[:3Annual Body Art Facility Permit <br /> III.APPLI NT INFORMO <br /> NAME: an Nja N: Phone: 2Vr , p <br /> <br /> <br /> <br /> Date of Birth: ')Ve*%t;PW OZ Gender: 4"For M (circle one) <br /> Identification Type: Drivers License MOther IdenIdentificationNo.: <br /> Facility where Body Art Service s Will be Provided �Matev <br /> FacilityName: ' 1► ��ma4v. I4 Owner: <br /> Address: S LOA <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Trai mg:Submit Certificate <br /> Date Completed: 01 Training Provided by: f rrcri <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[_]Laboratory Evidence of Immunity 4tQVaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1 �M BUSINESS NAME: *b� ?''rAA#.M& <br /> Location address: Shc(�((at-mewhl Qt - Suite: <br /> City: Lod I State: CA Zip: aS Zq2— County: <br /> Owner/Contact: Phone/Fax: <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 tha-ttp the best of aw4nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: flim lit <br /> Print Name: Title: <br /> 2 <br />