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s San Joaquin County 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton)(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 /> Tattooing 3ody Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> III.APPLICANT INFQ&MATION: <br /> .NAME: Phone: <br /> <br /> <br /> e <br /> ! BODY,ART ?!RACIITIOIIER=O Y ;` ,.W <br /> Date of Birth: 161' Gender: =or M (circle one) <br /> Identification Type: UlDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Pr v' ed <br /> Facility Name: Owner: <br /> UAr <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: y�� 1 o Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <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,( ):(Attach additional sheets as ess ry) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> Ci : State: Zi Count <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 Pi ting Notification and a es to operate in accordance with all applicable state and local <br /> requirements g rnipg saf ody art p aetices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certif t o t f edge and belief the statements made herein are true and correct. <br /> Signature: Date: ®k <br /> Print Name: Title: <br /> f2 <br />