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San Joaquin County 1868 East Hazelton Avenue <br /> StoIIS Environmental Health Department el:(209)46 -3220 <br /> p 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 /> MTattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[oAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: � <br /> <br /> <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �� l L-1 Gender: M or M (circle one) <br /> Identification Type: rMDrivers License MOther Identification No.: >' <br /> Facility where Body Art�Services Will be Provided L r I <br /> FacilityC Name: i o l 1 e P L cuo Owner: <br /> Address: 5�i Li c p o ,1 F,L n v c <br /> Evi n -months of Related Experience <br /> Facilit Name: Owner: <br /> Address: <br /> Service You Provided: <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[DLaboratory Evidence of Immunity 4®Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1 BUSINESS NAME:�1 p <br /> SA�� �O� --- <br /> Location address: 5-1Lk T fl U ^yG Suite: <br /> City: STdL ,'--T-b ../ State: Zip: C'Z®� )County: <br /> Owner/Contact: �--DIZU r-- 7 1 Phone/Fax: �.Oq—��t�i— 8111 O4b T <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 th best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: f <br /> Print Name: Title: O'W k-vz <br /> FOR OFFICE USE ONLY Z 3 3 q / <br /> Program(PE): OFees: 1 52 Authorized by(REHS): ! Date Entered: q <br /> t2 <br />