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1868 East Hazelton Avenue San Joaquin County Stockton, (209) 46 -3220 Environmental Health Department Tel: (209) 464-0138 3420 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 definitions) MTattooing MBody Piercing 1=11VIechanlcal Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. :1 1WAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2�Annual Body Art Facility Permit a II L APPLICANTjNFORMA ON: NAME: BODY ART PRACTITIONER ONLY V. FACILITY LOCATION (S): (Attach additional sheets as necessary rr77 Q Gender: F or M (circle one) Date of Birth:pL Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided S Facility Name: S Owner: lJl Address: ZIQ State: Zip: County: Evidence of Six -months of Related Experience V. A Facility Name: s C(7 Owner: Address: Owner/ Contact: Service You Provided: Phone/ Fax: LL QLOAV Supervisor Name and Contact Information: k Bloodborne Pathogen Training: Submit C.,ertiifificate b sm Davila• Date Com feted: -rTn Provided Hepatitis B vaccination Status: Choose One and Submit Documentation 1r'lCertlfication of Completed Vaccination 3r7Contraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4MVaccination Declination ) 1. BUSINESS NAME: FOR OFFICE USE ONLY Program (PC): N(IG Fees: 8IS.7 Location address: Suite: City: Authorized by (RENS): 66VJ.L. L( Date Entered: State: Zip: County: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip; County: 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 art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify tat to e b t of my knowledge and belief the statements made herein am true and correct. Signature: _ Date: Print Name: Title: Authorized by (RENS): 66VJ.L. L( Date Entered: