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Aillik San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health De artment Stockton, cn 95205 <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 /> Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1r.3;qAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Pierc <br /> <br /> \ /!�//� <br /> NAME: IMZ l j,(10�0. i Phonh a q / `r 6 <br /> HOME ADDRESS: 1(07,1 Al t?eyk-,, /ev Ave, <br /> n Email: C ( �,C on, <br /> Cit State: Zip: r/ County: 5ofl'1 I <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 3 / T< Gender: F or (circle one) <br /> Identification Type: CoDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided 1 <br /> Facility Name:—Tow Ia e_ �6 Owner; � -e>71:� <br /> Address: 1 In, a;i Q `i57,-10 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Blcodborne 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 3=Contra Indicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: Stater 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 cc'r tl at to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): 14110 Fees: 4t ( g ,2 Authorized by (REHS): 61 u t1 Date Entered: <br /> f2 <br />