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• San Joaquin County + 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> IMP Environmental Health Department 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 RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> 0eranding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT FORM N: oo <br /> NAME: 14,411 /� ` Phone: <br /> <br /> <br /> <br /> CTITIONERONLY . <br /> Date of Birth: "'L —S 7Gender: <br /> <br /> Facility where Body Art Services Will be Pro ided <br /> FacilityName: Owner: <br /> Address: 2 1 UZ Q C ' <br /> Evidence of Six-months of ReAted Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: ubmit Certificate <br /> Date Completed: 22 1 Training Provided by: C d <br /> Hes B Vaccination Status:Choose One and Submit Documentation <br /> nI <br /> Certiflcation of Completed Vaccination 3 MContra Indicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets a necessary) <br /> 1. BUSINESS NAME: a vi <br /> Location <br /> Gaddress: I IAI tjad. jX i4IQ S u ite: <br /> City: state: G 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 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 s�y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: & ,2 6�: p is f1t9l)E'er <br /> ` 5 <br /> FOR OFFICE 0911FONLY <br /> Program (PE): Fees Authorized by (REHS): Date Entered: I=- Vle <br /> 2 <br />