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San Joaquin County <br /> 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department <br /> Faxl: (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 MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> =Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1rMAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: d <br /> go-HONAME: QQ Q r'1 I�ak-t Phone: 2O'js /Igo- <br /> HOME <br /> ME ADDRESS: 3 fl2— -Se Email: fet <br /> Cit State; CP <br /> Zi 330 Count l CO&r) <br /> BODY ART PRACTITIONER ONLY <br /> Q -1 <br /> Date of Birth: (7 S 0 J- Gender: F or MM (circle one) <br /> Identification Type; VIDrivers License MOther Identification No.: y Yin 14 <br /> Facility where Body Art Services Will be Provided oa m 8-sca-pC <br /> Facility Name: 3L(2-2— W Homweik_c Owner: ` <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: 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 /> 1r__jCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[=Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/ Fax: <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 the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: d� _ 311Date: <br /> Print Name: TQIPAQ1 Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): l4 11 Q Fees; Authorized by(RENS): 61 N&14 Date Entered: <br /> r2 <br />