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San Joaquin County 1868 East Hazelton Avenue <br /> ° Environmental Health Department Stockton,CA 95205 <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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[nAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: / <br /> NAME: Phone: —1 <br /> HOME ADDRESS: 1WL Email: I nCjc�n <br /> tat <br /> Cit : C Se: Zi County: 1 / <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: C, Gender: F7J or r M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: ba Vooa <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 Trainin : Submit Certificate I /� <br /> Date Completed: -1 (2 ? 1 TrainingProvided b ` �I►^a I f) I <br /> Hepatitis B Vaccination St tus: Choose One and Submit Documentation <br /> 1r'qCertification of Completed Vaccination 3r--IContraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATIONS):(Attach additional sheet as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: W H Z Suite: <br /> CitC)TqclState: Zi : Cou t : !+ 1� V IIS <br /> Owner/Contact: I Phone/Fax: OF, <br /> Ci <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 a best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Q g11a <br /> Print Name: e Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): /(' Fees: (SLAuthorized by (RENS): Date Entered: <br /> if 2 <br />