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~ M.nVi ° • San Joaquin County 1868 East Hazelton Avenue <br /> 2,� 9y <br /> 95205 <br /> Environmental Health Department Stockton)46 -3420 <br /> F. <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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> ,Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1�Annual Body Art Practit asp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORM TION: <br /> NAME: Phone: -571,0 70/-If <br /> HOME ADDRESS: /L/Z T d Email: 6 / <br /> City: " i—Cf Lry State: eel Zip: /fZ J� Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or W (circle one) <br /> Identification Type: Imbrivers License MOther Identification No.: <br /> Facility where Bo d Art Services Will be Provides) I—Itl Facilit Name: I , TOwner: <br /> Address: 2Y212 Zd % v � <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 Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> lw <br /> 1. BUSINESS NAME: v ,''1y Y - z✓ <br /> Location address: ,?�,�i — �� �/ Suite: <br /> City: l Gt State: Zip: 7 J j County: <br /> Owner/Contact: L- - Phone/ Fax: 202— E U 5 <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 Notificiltion and agrees to operate in accordance with all applicable state and local <br /> requirements governi afe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify th to t e best of my knowledge and belief the statementre true and correct. <br /> Signature: /� Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(RENS): bate Entered: <br /> If2 <br />