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• 'f. • San Joaquin County • 1868 East Hazelton Avenue <br /> IN <br /> Environmental Health Department Stockton,CA 95205 <br /> 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. PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> EidTattooing r7Body Piercing F7mechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQUIR REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i 7Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 �Annual Body Art Facility Permit <br /> III.APPLICANNT INFORMATION: <br /> NAME: .i d s(.) T?i Phone: <br /> HOME ADDRESS: 422H ,�1 oaseli At CAVA Email: <br /> City: 5t,0 +oP- State CA Zip: 55-1 07 County• <br /> BODYART•PRACTITIONER ONLY.`:. <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: ITS <br /> Facility where Body Art Services Will be Provided <br /> Faclli Name: 47 Owner: Z <br /> Address: i C <br /> Evidence of Six-months of Related Expe nce <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Traini g:Submit Certificate /� <br /> Date Completed: Trainin Provided b irk <br /> A A &&A�J&jr,. <br /> Hepatitis B Vaccination tatus: Choose One and Submit Documentation 10 <br /> IMCertiflcation of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2M Laboratory Evidence of Immunity 4MVaccination 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 that to t est of my Prydedge and belief the statements made herein are true and correct. <br /> Signature: Date: 1.- ) -7- 13 <br /> Print Name: Title: a iia <br /> FOR OFFICE USE,ONLY ; � <br /> Program (PE) Fees Authorized by(REHS) Date Entered <br /> f2 <br />