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r <br />- --- -- - - <br />• <br />- - - <br />San Joaquin County <br />Environmental Health Department <br />0 -;k -� 12 <br />j 1 (-)((- <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/&W&.����I, <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION V <br />I. PROCED ES TO BE PERFORMED: Check all that apply (see back for definitions) ) i.) N 2 9 2012 <br />�ttooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding OPermarient Cosmetics ENNWWROWENTALHEALTH <br />-- ERWCES <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />iAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2M_ nnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: •- 7-3-- 7 G Gender: le one) <br />Identification Type: Drivers License MOther Identification No.: <br />City: <br />State: Zip: <br />Facility where Body Art Srvices Will be Provided <br />FacilityName: ner <br />Address: -, A <br />Phone/ Fax: <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: Y <br />Supervisor Name and Contact Information: r ! <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />County: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[DLaboratory Evidence of Immunity 4[:3Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City• <br />State: Zip: <br />County: <br />Owner/ Contact: <br />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 the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: 44 Date: <br />Print Name: Title: 'TM- oC-0 <br />FOR OFFICE USE ONLY /L p <br />Program (PE): Fees: Authorizedby (RENS): l/1y Date Entered: 4 3i Z <br />f <br />