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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />-= <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 MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding ffPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2E]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION:: <br />NAME: 0 0"Im pVIU&m1Tu j Phone: 7nN'Q0, 46 <br />1 <br /> <br />IV. FACILITY LOCATION (S): <br />Date of Birth: <br />�1 <br />A <br />I <br />Gender: <br />or M (circle one) <br />Identification Type: r Drivers License MOther <br />Identification No.: <br />Facility where Body Art l erviGes Will ye Provided <br />FacilityName: NM <br />Owner: ,1d <br />1r11f14Qn'1 <br />Address: 4bLlb <br />VQ <br />ON SUIT <br />41 <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 />1 ertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4MVaccination Declination <br />(Attach additional sheets as necessary) <br />1. BUSINESS NAME: IIK, Hidrten Gym <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 />reM uirements governing safe body art practices or practices governing mechanical stud and. clasp ear piercing. <br />I hereby certify t b�\stPlfAm'y knowledge and belief the statements made herein are true and correct. <br />Signature: ya a C V' Date: <br />Print Name: UMMA KM MITH Title: <br />FOR OFFICE USE ONLY <br />Program (PE); 1i <br />ll(J Fees: /," Authorized by (RENS): Date Entered: <br />