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San Joaquin County 1e6e easy Hazelton Avenue Stockton, CA 95205 Environmental Health Department Tel: (209) 468-3420 -^ P Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1 Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification 2 Annual Body Art Facility Permit III. APPLICANT INFORMATION: I ' BODY ART PRACTITIONER ONLY Date of Birth: Tp beor Iq 200Gender: Facility where Body Art Services Will be Provided Facilityiyy Name: I � ue4 oL Poke. Owner: Address: 22A V1 In 51 Evidence of Six -months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by; Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4 Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary ) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the,best of my knowledge and belief the statements made herein are true and correct. Signature: iR1 Date: Ju �N '2022 Print Name: Q ; I q v\ ;inn ' Title: FOR OFFICE USE ONLY Program (PE): 4110 Fees: S t Authorized by (REHS); COP Date Entered: ) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the,best of my knowledge and belief the statements made herein are true and correct. Signature: iR1 Date: Ju �N '2022 Print Name: Q ; I q v\ ;inn ' Title: FOR OFFICE USE ONLY Program (PE): 4110 Fees: S t Authorized by (REHS); COP Date Entered: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the,best of my knowledge and belief the statements made herein are true and correct. Signature: iR1 Date: Ju �N '2022 Print Name: Q ; I q v\ ;inn ' Title: FOR OFFICE USE ONLY Program (PE): 4110 Fees: S t Authorized by (REHS); COP Date Entered: