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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA -3420 <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 />ooing r7Body Piercing MMechanical Stud and Clasp Ear Piercing <br />LJ <br />Branding ®Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ' <br />Rnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />Annual Body Art Facility Permit <br />II: <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION ( <br />USE <br />1 / <br />Date of Birth: <br />Gender: M <br />or M (circle one) <br />Identification Type: twivers License reeeeeeelOther <br />Identification No.: <br />e(((() <br />Facility where Body Art Services Will be Provided <br />Fees: dj$o2 <br />Authorized by <br />'Facility Name: S <br />Owner: <br />Address: <br />Evidence of Six-monthsof Rela d Exper"yence <br />Facility Name: 1pit��!/�ll. <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Tr fining; qubmit Certificate <br />Date Completed: Trainin Provided <br />/' l/l <br />by; C 7 ✓l -O VL <br />Hepatitis B Vaccination tatus: Choose One and Submit Documentation 61 <br />0 <br />1QCertlfication of Completed Vaccination <br />3=Contraindicated for Medical <br />Reasons <br />2=Laboratory Evidence of Immunity <br />4MVaccination Declination <br />S): (Attach additional sheets as necessary) <br />2. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <br />The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner <br />Registration and/or Mechanical <br />Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br />requirements governi g safe bod art practices r practices governing mechanical stud and clasp ear piercing. <br />I hereby c rtify at o the best f y kno ge and belief the statements m de herr <br />er in are true and correct. <br />Signature: Date: <br />Print Name; Title: On <br />OFFICE <br />USE <br />ONLY <br />Inn (PE): <br />e(((() <br />Fees: dj$o2 <br />Authorized by <br />(REHS); 61NC,H Date Entered: <br />