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41 <br />x San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />"4ac.o"p 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 coPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3[--IMechanical Stud and Clasp Ear Piercing Notification <br />2PAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br />Date of Birth: <br />Gender: (nor MM (circle one) <br />Identification Type: Drivers License Mother Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Owner: ^, <br />Address: vv (11 t1 <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 />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1=Certification of Completed Vaccination 3=Contraindicated 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: State: 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 certify that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: A_A _ if VLjA Date: q / Lo / X-1 <br />Print Name: q A,j jMi Title: t<1,A,,?VVt-,Ar <br />FOR OFFICE USE ONLY <br />Program (PE): A-1 I IO Fees: d Z,�, �j Authorized by (RENS): 66kM &-,-I Date Entered: <br />