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1 1 • • <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Department Stockton)46 -3220 <br /> Environmental Health De <br /> p Tel: (209)4b$-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 /> MTattooing QBody Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding IzPermanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 21Annual Body Art Facility Permit <br /> III.APPUCA14T INFORMATION: q/�( <br /> NAME: r�ifW rA k ) 11� Phone: I!U I, 'L111k aC w _` <br /> <br /> <br /> Date of Birth: �"6�S Gender: F r MM circle one) <br /> Identification Type: EoDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: U/ 4 C Owner:( <br /> Address: N• K <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 <br /> Date Com leted: ��J ( Training Provided b riTi •COW) <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> I, Certification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4[=]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: N• G Suite: <br /> City.. � ' 5 State: zip: :�44) County:y j <br /> Owner Contact: r' Phone Fax: . 43 o <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 cert! h t to the b o my o led nd belief the statements made erein are true and correct. <br /> Signature: Date: _�,,.R <br /> Print Name: Title: <br /> f2 <br />