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' urt,lp pk San Joaquin County 1868 East Hazelton Avenue <br />:71sy Environmental Health Department stockton,cg982o6 <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. PROCEDU S TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing MBody Piercing =Mechanical Stud and Clasp Ear Piercing <br />=Branding =Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />I Annual Body Art Practitioner Registration 3=Mechanlcal Stud and Clasp Ear Piercing Notification <br />2=Annual Body Art Facility Permit <br />Ix <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: <br />Gender: M or r M (circle one) <br />Identification Type: rivers License Other <br />Identification No.: <br />Facility where Body Art Services Wil be Provided <br />rr <br />' /t <br />FacilityName: L <br />Owner: v\ <br />w' 11 <br />Address: Iv�Li�. ST <br />1 n <br />�� �'� 40 W <br />_ <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 <br />by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1.=Cert1ficatlon of Completed Vaccination <br />3=Contraindicated for Medical Reasons <br />Z=Laboratory Evidence of Immunity <br />4=Vaccination Declination <br />) <br />Owner/ Contact: Phone/ Fax: <br />The undersigned hereby applies for a Body Art Facility Perm(t 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 tha tot a �� y knowledge and belief the statements 1made <br />�herein <br />i are true and correct. <br />Signature: /I Date: <br />Print Name: 1 Title: <br />FOR OFFICE USE ONLY ,y <br />Prograjn (PE); P� Fees: W 19 <br />2 � Authorized by (REHS); Date Entered: <br />