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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 />D!jTattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br />®Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />11SIAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />II; <br />Date of Birth: L—Ml L-vI — -i — ::) Gender: I F I or M circle one) <br />Identification TVDe: MDrivers License MOther Identification No.: ; <br />Facility where=:UW10QC- <br />ces Will be Provided �!Facilit Name:Owner: G C-1 �9( Y ► r le <br />Address: H 2 ® - <br />Evidence of Six -months of Related Experience <br />Owner: <br />Supervisor Name and Contact Information: l- Qj� c? v23 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date ComDleted: / 10 ®` ? Trainina Provided bv: <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 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <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 p ices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to the of knowledge and belief the statements made herein are true and correct. <br />Signature: Date: (o-1(0— 1 3 <br />Print Name: 4 2, Title: M. <br /> <br />