COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

_<. San Joaquin County 1868 East Hazelton Avenue Environmental Health Department Stockton, CA 95205 Y�,veq, Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1MAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 20Annual Body Art Facility Permit II BODY ART PRACTITIONER ONLY Date of Birth: _ Gender: F or MM (circle one) Identification Type: Mrivers License r7 Other Identification No.: Owner/ Contact: Facility where Body Art Services Will be Provided 1— FacilityName: .CQ.{l/Il_,S( V'✓WSJ � Owner: Address: ta'PLP, F llowlL Evidence of Six -months of Related Experience Facility Name: --- � Owner: Location address: Address: Suite: Service You Provided: State: Zip: Supervisor Name and Contact Information: Owner/ Contact: Bloodborne Pathogen Trainin : Submit Certificate Date Completed: Training Provided la : Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContraindicated for Medical 2[=Laboratory Evidence of Immunity 4 Vaccinatlon Declination Reasons IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State• Zip• Countv' Owner/ Contact: Phone/ Fax' 2. BUSINESS NAME: Date Entered: Location address: Suite: City: State: Zip: County' Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that ttoo,ti st my knowledge and belief the statements made 1;iereip are true and correct. Signature: !• Date: �I / / / / )L / Print Name: '�, Title: St FOR OFFICE USE ONLY Program (PE): `JJ J /b Fees: � &2 Authorized by (REHS): 6 IN (&14 Date Entered: