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San Joaquin County 1868 East Hazelton Avenue <br />Sto05 <br />Environmental Health Department el: (209)46 93420 <br />P 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 Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQU ED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />1 Annual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />BODY ART PRACTITIONERONLY <br />Date of Birth: <br />Gender: al, or MM (circle one) <br />Identification Type: ADrivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />� <br />Facility Name: V 0G7il� <br />Owner: <br />Address: <br />Authorized by <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />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 />2MLaboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <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 totha o my knowledge and belief the statements made herein are true and correct. <br />Signature: O _ 1 /1— Date: 5 -Q. 2� <br />Print Name: CIAQ4l(& �(Vr 1L"�D,t/ Title: ok�N of <br />FOR OFFICE <br />USE <br />ONLY <br />Program (PE): <br />Fees: <br />Authorized by <br />(REHS): Date Entered: <br />