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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />:l.3R.a 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 Mmechanical Stud and Clasp Ear Piercing <br />Branding 'Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[oAnnual Body Art Facility Permit <br />II: <br />% <br />BODY"ART PRACT T10NER ONLY <br />Date of Birth: Z Gender: F or MM (circle one) <br />Identification Type: rivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided 1 w 1 <br />FacilityName: O W K mO'r uv 3 Owner: <br />�1 n i1.,,✓ , c <br />'C 1 WA tal"'1J <br />Address: L L C <br />Evidence of Six -months of Related Experience 1 V� <br />FacilityName: S IXU t , � Owner: <br />Address: CA 1 rC4e_ <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate �� <br />Date Completed: 5-1 V-17TrainingProvided by: �� C) 31 <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r7Certlflcatlon of Completed Vaccination 3@,Contraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): <br />Owner/ Contact: LI <br />2. BUSINESS NAME: <br />additional sheets as neceesys�ary) <br />yecLL <br />7 <br />Vpi, <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 certifVtom <br />of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: I �� L1'3 <br />Print Name: Q YM Title: ` 11\__P_y_ <br />