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eQ 4 San 'oaquin County 1868 East Hazelton Avenue <br /> w 95205 <br /> EnVironmentali Health Stockton)46 -3420 <br /> Department* Tel: (209)468-3420 <br /> a ""a 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 /> attooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding OlPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 0 <br /> NAME: Phone: ! <br /> <br /> <br /> DY ART P ITIONER<ONLY: <br /> Date of Birth: �Z I Gender: F r M (circle one) <br /> Identification Type: MbriversLicense Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <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 Training: Submit Certificate V^,A S INIV <br /> `i9 <br /> Date Completed 7 Training Provided by: �0 `T" 074)03 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory 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 /> 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 the a my knowledge d bell the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: t ® ` Title: <br /> Fiiitt LY <br /> 1�rogirarrl-(PE) Fees: by(CRS) Date Entered; <br /> f2 <br />