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San Joaquin County Environmental Health Department 1868 East Hazelton Avenue Stockton, CA 95205 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 definitlons) F7Tattooing OBody Piercing Mechanical Stud and Clasp Ear Piercing MBranding Mpermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. 1oAnnual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit ,.'IIII. APPLICANTi,INFORMATION: W .NAME: MII,I'eft V(II16 IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) Location address: Suite: city: state Zip Countv 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 a t practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to he st of my knowledge and belief the statements made herein are true and correct. Signature: [/fl Date: _ 0 N 1231Z1 Print Name: ffil Q,IICVl(J VA Title: FOR OFFICE USE ONLY Program (PE): WI I o Fees; I Z U V Authorized by (REHS); Date Entered: BODY ART PRACTITIONER ONLY Date of Birth: Gender: DK or MM (circle one) Identification Type: FZIDrivers License MOther Identification No.: (� Facility where Body Art Services Will be Provided Facility Name: Owner: Address: Evidence -of -Six -months of Related Experience FacilityName: —� Owner: Address: -- Service You Provided: Su ervlsor Name and Contact Informatlon: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1=Certification of Completed Vaccination 3MContraindicated for Medical Reasons 2[=]Laboratory Evidence of Immunity 4[EVacclnation Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) Location address: Suite: city: state Zip Countv 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 a t practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to he st of my knowledge and belief the statements made herein are true and correct. Signature: [/fl Date: _ 0 N 1231Z1 Print Name: ffil Q,IICVl(J VA Title: FOR OFFICE USE ONLY Program (PE): WI I o Fees; I Z U V Authorized by (REHS); Date Entered: