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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95Z205 <br /> Environmental Health Department Tel: 1209)468-3420 <br /> Fax: '209)464-0738 <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 =Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1t6Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Q Phone: — 9 <br /> � r1 <br /> HOME ADDRESS: ) L Email: - \ N��\. C(,N-\ <br /> Ci= c n State: zip: X S County: Gl-\ G <br /> Date of Birth: G Gender: M o M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> facility Name: L ( I Z to Owner: <br /> PAdress: I ,- & LE C <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service"ou Providec: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathcgen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1r--ICertificaticr of Completed Vaccination 3[:DContraindicated for Medical Reasons <br /> 2MLeboratory Evidence of Immunity 4['�:]Vaccination Declination <br /> IV. FACILITY LOCATION II(S):(,Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: l L�4 D(CG\NkS �c.� / Grc� �('ZtC'k C, <br /> Location address: L 0 )D,( �-�cC ,��� Suite: <br /> City: S.Accwr' State: L Zip: �{�ZG 7 County: 10Q(n . <br /> Owner/Contact: Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Lccation 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: <br /> Print Name: �;W j`C )��,C r Title: <br /> FOR OFFICE USE ONLY <br /> Program (:)EI �.jj� (� Fees: 1 Authorized by (REHS): Date Entered: <br /> fz <br />