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San 3oaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <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 FlPermanent Cosmetics 1 <br />II. REQUI <br />�D REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[:]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: r <br />NAME: K(�D" Al ��D &A%< Ing Phone: ((-q/-5)61?q _ I/x <br />U <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: i I oz- G Gender: M or M (circle one) <br />Identification Type: FMDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: 3 T CO 7 %6✓L`0';A Owner: A j' a <br />Address: ZZ+i' S>✓, fG 1 �53�� <br />Evidence of Six -months of Related Experience <br />Facility Name: IU U(; ��i GvGr >7 Owner: , 11 !1 <br />040 <br />Address: T �h SE- C! <br />i <br />Service You Provided: <br />Supervisor Name and Contact Information: ' l; U U <br />Bloodborne Pathogen Training: Submit Certificate n <br />Date Completed: 4A6, -v TrainingProvided by: PYD 1✓Lt;ni S <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 r__j Certification of Completed Vaccination 3r--IContraindicated for Medical Reasons <br />2[:DLaboratory Evidence of Immunity 4EVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <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 dasp ear piercing. <br />I hereby certify that to f my knowledge and belief the statements made herein are true and correct. <br />'� 0� ��3 ZQj <br />Signature: Date: <br />Print Name: FD - Title: <br />OFFICE USE ONLY <br />3m (PE): Fes: Authorized by (RENS): Date Entlered: <br />