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San Joaquin County iB66 tan nazeicorf „venue <br />Stockton, CA 95205 <br />Environmental Health Department 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 />QTattooing QBody Piercing MMechanical Stud and Clasp Ear Piercing <br />a Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 f' Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2[:IAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: [;L>rtQfill C' L1 <br /> <br /> <br /> <br /> <br /> <br /> �, <br />BODY ART PRA <br />ONER ONLY <br />Date of Birth: 103 0 <br />Gender: F or MM (circle one) <br />Identification Type: r77TDrivers License ft6pther <br />Identification : <br />Facility where Body Art Services 1Wiilll be Provided <br />Facili Name: 1-Y- j0()M -rCA-k h O Gl//�� <br />)eYGlh owner: G t* I✓��� <br />Address: !rC 6A TMW <br />SNAIJ <br />Evidence of Six -months of Related Expe ' nce <br />Facility Name: 0 e lC <br />Owner: j - <br />Address: T <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />! �j <br />0 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed:_ Training Provided by: PrJ4"log <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2a Laboratory Evidence of Immunity 4®Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as <br />ICT ;:F. 1 r" 9'S 7 Suite: <br />4- <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: Date: �J(2$ 120? <br />Print Name: r�)Yt Title: <br />FOR <br />IFOR OFFICE USE ONLY I <br />Program (PE): Fees: Authorized by (REHS): iDate Entered: <br />