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0 <br />San Joaquin County <br />Environmental Health Department <br />1666 East Hazelton Avenue <br />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 />12 Tattooing r7Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding E3Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply, <br />ImAnnual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br />2E]Annual Body Art Facility Permit <br />+i <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: \ _ <br />Gender: M or <br />(circle one) <br />Identification Type: Drivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />(REHS): Date Entered: <br />Facility Name: IivAt <br />1 <br />Owner: k'iA/�. <br />`- <br />T <br />Address: <br />CA,5(1601 <br />Evidence of Six -months of Related Experience <br />Facility Name. - -- - - - <br />Address._-"-- --_ --- - - - _ <br />- - <br />Service You Provide •-- <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com letedti t0`,',- Training Provided <br />b <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3 Contraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity <br />4 Vaccination Declination <br />) <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 pract' es or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify tat the 1 es �y et ge and belief the statements made herein are true and correct. <br />Signature: f I Date: <br />Print Name:Inan Title: <br />FOR OFFICE USE ONLY <br />Program (PE): P1ll G Fees: a/54 <br />Authorized by <br />(REHS): Date Entered: <br />