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San Joaquin County 1868 East Hazelton Avenue <br />StoEnvironmental Health Department el: (209)kton, 46 -3220 <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 />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding 63rermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />l 1 Annual Body Art Practitioner Registration 3r"IMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br /> <br />IV. FACILITY LOCATION (S): (Attach additional sheets asnecessary) <br />Date of Birth: hcl <br />Gender: F or M (circle one) <br />Identification Type: MDrivers License MOther <br />Identification No.: , <br />Facility where Body Art Services Will be Provided <br />LL,, <br />Facilit Name: �' t'L 1u1%&try cuw1'1 L U.l <br />Owner: SIS GC, M(tvri `)CL S <br />Address: qcj <br />IC. <br />ICAN <br />i5_ (D <br />Evidence of Six -months of Related Experience <br />Facilit Name: U r ban <br />C <br />Owner: >� <br />Address: <br />nit <br />Service You Provided: fl+ <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: (D :)f3 aL� Trainingp Provided <br />b : ' `AVL (A, kj <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity <br />4�cclnation Declination <br />y, <br />1M U1/Y ClP� it <br />Location address: ('aYP�e+� Suite: A <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 certifykhat, to the best of my knowledge and b tef the statements made herein are true and correct, <br />Signature: Q LiA-A D, W1 I A A J Date: <br />Print Name: Q Title: ry1tSM <br />FOR OFFICE USE ONLY 1 <br />Program (PE): Fees: X5 4 Authorized by (REHS): (00 Date Entered: F�3u/1L <br />