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41 1- % San Joaquin County 1868 East Hazelton Avenue <br />�.; Environmental Health Department Stockton, CA 95205 <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 OBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding IV <br />Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply, <br />IAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification2r9Annual Body Art Facility Permit <br />Ia- <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: I f IP. �(��(�P.YI %rPI11 <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 <br />state and focal <br />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that a best of y kr I ge rYffbelief the statements made herein are true and correct. <br />Signature: Date: w h 5l apaii <br />Print Name: Title: 11 <br />FOR OFFICE USE ONLY bb ) <br />Program (PE): q1jo Fees: �� Y• <br />Authorized by (KERS): f•NAO <br />Date Entered: �dllf L7 <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 0210 jjq0 <br />Gender: F <br />or M (circle one) <br />Identification Type: Drivers License Other <br />Identification No.;. <br /> <br />Facility where Body Art Services Will be Provided <br />• s <br />Facility Name:The <br />Owner: 1 <br />Address: 4595 Geoi— <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=Certification of Completed Vaccination <br />3MContralndicated for Medical <br />Reasons <br />2[=Laboratory Evidence of Immunity <br />4 9Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: I f IP. �(��(�P.YI %rPI11 <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 <br />state and focal <br />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that a best of y kr I ge rYffbelief the statements made herein are true and correct. <br />Signature: Date: w h 5l apaii <br />Print Name: Title: 11 <br />FOR OFFICE USE ONLY bb ) <br />Program (PE): q1jo Fees: �� Y• <br />Authorized by (KERS): f•NAO <br />Date Entered: �dllf L7 <br />