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a== San Joaquin County 1868 East Hazelton Avenue <br /> A."L�� t` 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: C eck all that apply (see back for definitions) <br /> F—ITattooing =Kody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding =Permanent Cosmetics <br /> II. REQUIREO REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3r--IMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLIC{;4ANT INFORMATION: <br /> NAME: ' 4,11 Phone: mad�// <br /> HOME ADDRESS: , c Email: '' <br /> City: State: Zip: (i County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: F71Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: J65 � '�\, Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ,25 ��L Owner: <br /> Address: <br /> Service You Provided: Lj <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 /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 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 th o the be of my kn wledge and belief the statements made he ein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: e� <br /> FOR OFFICE USE ONLY <br /> Program (PE): r-I110 Fees: 0 152 Authorized by (RENS): 351 N" Date Entered: <br /> If 2 <br />