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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 Plercing SCp o <br />Branding Permanent Cosmetics E G 8 <br />II. REQUIED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. PERM�TiFNTAi <br />1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing NotificationSFR� <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 21 2 cx) <br />Gender: or M (circle one) <br />Identification Type; <br />Drivers License Other <br />Identification No.: <br />Facility where Bod Art Services Will 6e Provided <br />Facility Name: U <br />Owner: <br />// <br />Address: Qw <br />Evidence of Six -months of Related Experience <br />FacilityName: <br />Owner: <br />Address: <br />Service You You Provided; <br />Supervisor ervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: (� Trainin Provided by: <br />%t <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />I Certification of Completed Vaccination 3�Contra indicated for Medical Reasons <br />W <br />2=Laboratory Evidence of Immunity 4®Vaccination DeclinatiolHold oqh,� lrra <br />FACILITY LOCATION (S :: (Attach additional sheets as necessary) <br />1, BUSINESS NAME: A l uemic ✓� <br />/B <br />Vq ) e T\ vV 1 <br />Location address: <br />2 <br />y, )o7 cAn-i 51 <br />Suite: <br />2. BUSINESS <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 b f y kngwigdge and belief the statements made herein are true and correct. <br />Signature: / � Date: _g1g12OPrint Name: dd Title: <br />FOR OFFICE USE ONLV ( (]Q1 (� p 7 <br />Program (PE): jQ Fees: iS� Authorized by (RENS): (I u7I Date Entered:-I/l.'/LD <br />.ingtion <br />,wiser , <br />