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.'"1868 East Hazelton Avenue <br />77";° San Joaquin County <br />Department Stockton) CA -3220 <br />Environmental Health De <br />p Tel: (209) 468-3420 <br />v•a'; <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) - NZ74!; #[!Q <br />F—ITattooing Body Piercing Mechanical Stud and Clasp Ear Piercing 4,01?��8 <br />p <br />Branding Permanent Cosmetics ' N" 4l ?0 <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ���r/$, ---Ik `�� <br />i�Annual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification E$ <br />2[DAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 42-7- Gender: r7m or MM (circle one) <br />Identification Type: M77 Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: b / Owner: <br />Address: j t <br />Evidence of Six-month of Related Experience <br />facility Name: —'juE - / z Owner: <br />Address: i <br />Service You Provided: <br />.Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com feted: / Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r--ICertification of Completed Vaccination Sontraindicated 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: <br />Suite: <br />City: State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: <br />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 the best of my knowledge and belief the statements made herein are true and correct. <br />Signature:/G} ` ,/� Date: zZ z5 - <br />Print Name: lG. %iCr Title: <br />FOR OFFICE USE ONLY <br />Program (PE): r{! I n Fees: of /5G Authorized by (RENS): �,SiIyIS,�t Date Entered: <br />