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San Joaquin County Stockton, CA9szu� <br />Tel: (209) 468-3420 <br />Environmental Health Department pax; (209) 464.0138 <br />~� <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED! BCh�eY all t at apply (see back MC hanical Stud and Clasp Ear Piercing <br />OTattooing <br />Piercing <br />Branding EmPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES*Check ical Stud that and clasp Ear Piercing Notification <br />ICMAnnual Body Art Practitioner Registration 3 <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br />NAME: ` (O <br /> <br /> <br /> <br />BODY ART PRA ONlR ONLY <br />,/ C] Gender: F or M circle one <br />` <br />Date of Birth: C) _` <br />Identification T Drivers License other Identification No.: <br />Facility where Body Art Services Will be Provided nWnef. :i 1 uvCr�Z— <br />S <br />of Slz-months of Related Experience <br />Pathogen Training: Submit Certificate <br />Or <br />Date Com leted• <br />Hepatitis B Vaccination Status: Choose One and Submk Roc31me�nCo oaindicated for Medical Reasons <br />I�Certification of Completed Vaccination LL.... <br />$Vaccination Declination <br />Laboratory Evidence of Immunity <br />2� <br />IV. FACILITY LOCATION (S): (Attach additional sheetsas necessary) <br />2. BUSINESS NAME: <br />Suite: <br />Location address: <br />State: Z111Count <br />City: <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 the o th best of rty knowledge and belief the statements made herein are true and correct. <br />Signature: Date: 1 V C Print Name: Title: <br />FOR OFFICE USE ONLY � diPl(y1.{ Date Entered: <br />Program (PE): ril i O Fees: 15� Authorized by (REHS): <br />