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San Joaquin County 1868 East Hazelton Avenue <br />V <br />Environmental Health Department Stockton, CA 3220 <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. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br />ETattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />OBranding 112rpermanent Cosmetics <br />II. REQUID REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2r7Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />80DY ARTPRACTITIONER ONLY <br />Date of Blrth: <br />Gender: F or MM (circle one) <br />IdentlFlcation Type; Drivers License <br />Other <br />Identification No.: <br />Facility where Body Art Services Will be Provide <br />FacilityName; MP(V <br />Q <br />Owner: •� J a <br />Address: jq <br />I F, I Olih <br />S . s <br />Evidence of Six -months of Related Experience <br />Facility Name: Makeup Sftdto <br />Owner: <br />Address; 2JAI <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com leted: M &j Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1l'ICertification of Completed Vaccination 3QContraindicated for Medical Reasons <br />2=Laboratory Evidence of Immunity 4[::]Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as <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 />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to f t��/�he byes§—t"of my knowledge and belief the statements made herein are true �aJnd correct. <br />Signature: &6Z <br />����'U,� Date: ��7f'ober `"J� (ln l <br />Print Name: ��"I I n�i�� Title: <br />FOR OFFICE USE ONLY <br />Program � t <br />(PE): !j(k <br />O Pees: �_ Authorized by (RENS):' ���pt� 1��Date Entered: <br />